Provider Demographics
NPI:1144322090
Name:GARDNER, ALLEN S (MD)
Entity type:Individual
Prefix:DR
First Name:ALLEN
Middle Name:S
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 1:6128 BRANDON AVE STE 201
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:22150-2693
Mailing Address - Country:US
Mailing Address - Phone:703-780-2800
Mailing Address - Fax:703-780-0461
Practice Address - Street 1:6128 BRANDON AVE STE 201
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:VA
Practice Address - Zip Code:22150-2693
Practice Address - Country:US
Practice Address - Phone:703-780-2800
Practice Address - Fax:703-780-0461
Is Sole Proprietor?:No
Enumeration Date:2006-09-02
Last Update Date:2012-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101018446207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA8132486OtherMAMSI
VAB3800003OtherCAREFIRST BC/BS
VA95009502OtherUNITED HEALTHCARE
VA088909OtherANTHEM
VA4089095OtherAETNA
VA8132486OtherMAMSI
C61761Medicare UPIN