Provider Demographics
NPI:1023183829
Name:GARDNER, ROBERT WILLIAM
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:WILLIAM
Last Name:GARDNER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10458 CHATTEN COURT
Mailing Address - Street 2:
Mailing Address - City:CLEARLAKE OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:95423-7050
Mailing Address - Country:US
Mailing Address - Phone:707-274-9299
Mailing Address - Fax:707-274-9297
Practice Address - Street 1:6300 E. HWY 20
Practice Address - Street 2:
Practice Address - City:LUCERNE
Practice Address - State:CA
Practice Address - Zip Code:95458
Practice Address - Country:US
Practice Address - Phone:707-274-9299
Practice Address - Fax:707-274-9297
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-21
Last Update Date:2012-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG30366207QA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G303660Medicaid
CA00G303660Medicaid
CAA44393Medicare UPIN