Provider Demographics
NPI:1194026849
Name:LAWRENCE W GARDNER JR MD PA
Entity Type:Organization
Organization Name:LAWRENCE W GARDNER JR MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:
Authorized Official - Last Name:GARDNER
Authorized Official - Suffix:
Authorized Official - Credentials:MD, FACG
Authorized Official - Phone:239-574-8616
Mailing Address - Street 1:708 DEL PRADO BLVD
Mailing Address - Street 2:SUITE 5
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33990-5616
Mailing Address - Country:US
Mailing Address - Phone:239-574-8616
Mailing Address - Fax:239-574-4451
Practice Address - Street 1:708 DEL PRADO BLVD
Practice Address - Street 2:SUITE 5
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33990-5616
Practice Address - Country:US
Practice Address - Phone:239-574-8616
Practice Address - Fax:239-574-4451
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-11
Last Update Date:2011-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0034362207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL038581-600Medicaid
FL1972653632OtherNPI
FL79466OtherPTIN
FL038581-600Medicaid