Provider Demographics
NPI:1588722730
Name:GARDNER, WILLIAM GRANT (MD)
Entity type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:GRANT
Last Name:GARDNER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:1601 OWEN DR
Mailing Address - Street 2:SPECIALTY CLINIC
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28304-3425
Mailing Address - Country:US
Mailing Address - Phone:910-678-7313
Mailing Address - Fax:910-678-7279
Practice Address - Street 1:1601 OWEN DR
Practice Address - Street 2:SPECIALTY CLINIC
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-3425
Practice Address - Country:US
Practice Address - Phone:910-678-7313
Practice Address - Fax:910-678-7279
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2013-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2006-00081207R00000X, 207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8934556Medicaid
A76204Medicare UPIN
NC2051437Medicare PIN