Provider Demographics
NPI:1073796223
Name:RODDY A. GARDNER, D.O. P.C.
Entity Type:Organization
Organization Name:RODDY A. GARDNER, D.O. P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RODDY
Authorized Official - Middle Name:A
Authorized Official - Last Name:GARDNER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:480-967-7821
Mailing Address - Street 1:910 S PRIEST DR
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85281-5233
Mailing Address - Country:US
Mailing Address - Phone:480-967-7821
Mailing Address - Fax:480-967-1247
Practice Address - Street 1:910 S PRIEST DR
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85281-5233
Practice Address - Country:US
Practice Address - Phone:480-967-7821
Practice Address - Fax:480-967-1247
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-11
Last Update Date:2008-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ975208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZWCHHWMedicare PIN