Provider Demographics
NPI:1972590578
Name:GARDNER, PETER (MD)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:
Last Name:GARDNER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:92 JORDAN LANE
Mailing Address - Street 2:
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06903
Mailing Address - Country:US
Mailing Address - Phone:203-940-2995
Mailing Address - Fax:203-547-6194
Practice Address - Street 1:92 JORDAN LN
Practice Address - Street 2:
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06903-3914
Practice Address - Country:US
Practice Address - Phone:203-940-2995
Practice Address - Fax:203-547-6194
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-29
Last Update Date:2016-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT024317174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
010027907CT01OtherBC/BS ID #
25013OtherOXFORD ID #
061246885OtherUNITED HEATLHCARE ID #
4125202OtherAETNA
020183OtherHEALTHNET ID #
024317OtherCT CARE ID #
25013OtherOXFORD ID #