Provider Demographics
NPI:1144394776
Name:GARDNER, TRACI FURBERT (MD)
Entity Type:Individual
Prefix:DR
First Name:TRACI
Middle Name:FURBERT
Last Name:GARDNER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35 KENSICO RD
Mailing Address - Street 2:
Mailing Address - City:THORNWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:10594-1143
Mailing Address - Country:US
Mailing Address - Phone:914-449-6064
Mailing Address - Fax:914-449-6366
Practice Address - Street 1:35 KENSICO RD
Practice Address - Street 2:
Practice Address - City:THORNWOOD
Practice Address - State:NY
Practice Address - Zip Code:10594-1143
Practice Address - Country:US
Practice Address - Phone:914-449-6064
Practice Address - Fax:914-449-6366
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2220992080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYH48930Medicare UPIN