Provider Demographics
NPI:1265827356
Name:GARDNER, PHILIP (MD)
Entity Type:Individual
Prefix:
First Name:PHILIP
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 1:849 N SYRINGA ST
Mailing Address - Street 2:
Mailing Address - City:POST FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83854-8794
Mailing Address - Country:US
Mailing Address - Phone:208-777-1320
Mailing Address - Fax:208-777-1322
Practice Address - Street 1:849 N SYRINGA ST
Practice Address - Street 2:
Practice Address - City:POST FALLS
Practice Address - State:ID
Practice Address - Zip Code:83854-8794
Practice Address - Country:US
Practice Address - Phone:208-777-1320
Practice Address - Fax:208-777-1322
Is Sole Proprietor?:No
Enumeration Date:2015-04-06
Last Update Date:2024-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IDM-14854207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program