Provider Demographics
NPI:1962588111
Name:GARDNER, SAMUEL D (DO)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:D
Last Name:GARDNER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:203 S DAISY ST
Mailing Address - Street 2:
Mailing Address - City:SALMON
Mailing Address - State:ID
Mailing Address - Zip Code:83467-0000
Mailing Address - Country:US
Mailing Address - Phone:208-756-5600
Mailing Address - Fax:208-756-4169
Practice Address - Street 1:805 MAIN ST
Practice Address - Street 2:
Practice Address - City:SALMON
Practice Address - State:ID
Practice Address - Zip Code:83467-0000
Practice Address - Country:US
Practice Address - Phone:208-756-6212
Practice Address - Fax:208-756-6336
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-31
Last Update Date:2011-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDO-174207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID804213400Medicaid
G53441Medicare UPIN
1301638Medicare ID - Type Unspecified