Provider Demographics
NPI:1114055787
Name:GARDNER, MARK R (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:R
Last Name:GARDNER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4321 FIR ST STE 313
Mailing Address - Street 2:ST CATHERINE OCC HLTH
Mailing Address - City:EAST CHICAGO
Mailing Address - State:IN
Mailing Address - Zip Code:46312-3049
Mailing Address - Country:US
Mailing Address - Phone:219-392-7424
Mailing Address - Fax:219-392-7450
Practice Address - Street 1:4321 FIR ST STE 313
Practice Address - Street 2:
Practice Address - City:EAST CHICAGO
Practice Address - State:IN
Practice Address - Zip Code:46312-3049
Practice Address - Country:US
Practice Address - Phone:219-392-7424
Practice Address - Fax:219-392-7450
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-02
Last Update Date:2017-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036068695207R00000X, 2083X0100X
IN01059461A207R00000X, 2083X0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
769580Medicare ID - Type Unspecified
C41378Medicare UPIN