Provider Demographics
NPI:1144245465
Name:GARDNER, BRIAN
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:
Last Name:GARDNER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 FOX HUNT DR # 118
Mailing Address - Street 2:
Mailing Address - City:BEAR
Mailing Address - State:DE
Mailing Address - Zip Code:19701-2535
Mailing Address - Country:US
Mailing Address - Phone:302-832-1500
Mailing Address - Fax:302-832-5558
Practice Address - Street 1:5301 LIMESTONE RD STE 223
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19808-1265
Practice Address - Country:US
Practice Address - Phone:302-239-1933
Practice Address - Fax:302-239-1002
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2009-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DE13 0001305152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
DEU97066Medicare UPIN
DE019580S05Medicare PIN