Provider Demographics
NPI:1306821756
Name:GARDNER, TRESSA K (DO)
Entity Type:Individual
Prefix:
First Name:TRESSA
Middle Name:K
Last Name:GARDNER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 N PERRY ST
Mailing Address - Street 2:
Mailing Address - City:PONTIAC
Mailing Address - State:MI
Mailing Address - Zip Code:48342-2217
Mailing Address - Country:US
Mailing Address - Phone:248-338-5327
Mailing Address - Fax:248-338-5129
Practice Address - Street 1:50 N PERRY ST
Practice Address - Street 2:
Practice Address - City:PONTIAC
Practice Address - State:MI
Practice Address - Zip Code:48342-2217
Practice Address - Country:US
Practice Address - Phone:248-338-5327
Practice Address - Fax:248-338-5129
Is Sole Proprietor?:No
Enumeration Date:2005-12-08
Last Update Date:2009-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101012299207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4091747Medicaid
MIC56002045Medicare ID - Type Unspecified
MI4091747Medicaid