Provider Demographics
NPI:1033101696
Name:GARDNER, GERALDINE (DO)
Entity Type:Individual
Prefix:DR
First Name:GERALDINE
Middle Name:
Last Name:GARDNER
Suffix:
Gender:F
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:PO BOX 3290
Mailing Address - Street 2:
Mailing Address - City:LA GRANDE
Mailing Address - State:OR
Mailing Address - Zip Code:97850-7290
Mailing Address - Country:US
Mailing Address - Phone:541-963-2328
Mailing Address - Fax:541-975-5210
Practice Address - Street 1:900 SUNSET DR
Practice Address - Street 2:
Practice Address - City:LA GRANDE
Practice Address - State:OR
Practice Address - Zip Code:97850-1387
Practice Address - Country:US
Practice Address - Phone:541-963-2328
Practice Address - Fax:541-975-5210
Is Sole Proprietor?:No
Enumeration Date:2005-08-19
Last Update Date:2020-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOP60308505207RC0000X
ORDO194314207RC0000X
NV822207RC0000X
WY7383A207RC0000X
CA20A6134207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY123264900Medicaid
OR500769777Medicaid
NV2016356Medicaid
NVF15539Medicare UPIN
WAG8914098Medicare UPIN
WYW20829Medicare ID - Type Unspecified