Provider Demographics
NPI:1033151063
Name:GARDNER, STEPHANIE STEIN (MD)
Entity Type:Individual
Prefix:DR
First Name:STEPHANIE
Middle Name:STEIN
Last Name:GARDNER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:73 PRESTIGE LN STE 101
Mailing Address - Street 2:
Mailing Address - City:DAWSONVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30534-6370
Mailing Address - Country:US
Mailing Address - Phone:770-746-6380
Mailing Address - Fax:770-284-8380
Practice Address - Street 1:6300 HOSPITAL PKWY STE 375
Practice Address - Street 2:
Practice Address - City:JOHNS CREEK
Practice Address - State:GA
Practice Address - Zip Code:30097-2461
Practice Address - Country:US
Practice Address - Phone:770-800-3455
Practice Address - Fax:770-284-8380
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2022-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA032567174400000X
GA32567207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA032567OtherMEDICAL LICENSE
GA003136732BMedicaid
GA003136732CMedicaid
GA003136732AMedicaid
GA003136732CMedicaid
GA202I078452Medicare PIN