Provider Demographics
NPI:1134103591
Name:GARDNER, DANIEL (MD)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:
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 1:13725 MAR SCENIC DR
Mailing Address - Street 2:
Mailing Address - City:DEL MAR
Mailing Address - State:CA
Mailing Address - Zip Code:92014-3426
Mailing Address - Country:US
Mailing Address - Phone:858-560-5609
Mailing Address - Fax:858-560-5609
Practice Address - Street 1:4550 KEARNY VILLA RD
Practice Address - Street 2:SUITE 214
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-1578
Practice Address - Country:US
Practice Address - Phone:858-560-5609
Practice Address - Fax:858-560-5609
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG271042084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG271D40Medicaid
A43221Medicare UPIN
A43221Medicare ID - Type Unspecified