Provider Demographics
NPI:1023179850
Name:GARDNER, ROBERT S (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:S
Last Name:GARDNER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:R S ISAAC
Other - Middle Name:
Other - Last Name:GARDNER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:525 COLLEGE AVE
Mailing Address - Street 2:211
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95404-4118
Mailing Address - Country:US
Mailing Address - Phone:707-575-7647
Mailing Address - Fax:707-575-7739
Practice Address - Street 1:525 COLLEGE AVE
Practice Address - Street 2:211
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95404-4118
Practice Address - Country:US
Practice Address - Phone:707-575-7647
Practice Address - Fax:707-575-7739
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-13
Last Update Date:2009-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG177182084P0800X, 207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA40173Medicare UPIN
CA00G177180Medicare ID - Type Unspecified