Provider Demographics
NPI:1275984643
Name:GARDNER, JORDAN (DPM)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:GARDNER
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9322 BRITTANY DR
Mailing Address - Street 2:
Mailing Address - City:NEWBURGH
Mailing Address - State:IN
Mailing Address - Zip Code:47630-3412
Mailing Address - Country:US
Mailing Address - Phone:801-668-4541
Mailing Address - Fax:
Practice Address - Street 1:3801 BELLEMEADE AVE STE 110
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47714-0111
Practice Address - Country:US
Practice Address - Phone:812-485-1814
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-28
Last Update Date:2020-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY244152213E00000X
IN41000353A213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist