Provider Demographics
NPI:1194815480
Name:GARDNER, BRUCE (MD)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
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 1:1915 QUEEN ANNE AVE N
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98109-2549
Mailing Address - Country:US
Mailing Address - Phone:206-284-6132
Mailing Address - Fax:206-284-2566
Practice Address - Street 1:1915 QUEEN ANNE AVE N
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98109-2549
Practice Address - Country:US
Practice Address - Phone:206-284-6132
Practice Address - Fax:206-284-2566
Is Sole Proprietor?:No
Enumeration Date:2006-10-15
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00020877207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
5350424OtherAETNA
WA8102048Medicaid
WAGA5004OtherREGENCE BLUE SHIELD
WAAB24834Medicare ID - Type UnspecifiedMEDICARE
WA8102048Medicaid