Provider Demographics
NPI:1306827167
Name:GARDNER, MARK ROBERT (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:ROBERT
Last Name:GARDNER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:120 BUTLER ST
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33407-6107
Mailing Address - Country:US
Mailing Address - Phone:561-659-1510
Mailing Address - Fax:561-659-0495
Practice Address - Street 1:13005 SOUTHERN BLVD
Practice Address - Street 2:MEDICAL MALL 1 SUITE 122
Practice Address - City:LOXAHATCHEE
Practice Address - State:FL
Practice Address - Zip Code:33470-9206
Practice Address - Country:US
Practice Address - Phone:561-798-1649
Practice Address - Fax:561-791-8631
Is Sole Proprietor?:No
Enumeration Date:2005-11-09
Last Update Date:2010-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0068374207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
F92444Medicare UPIN
494072Medicare ID - Type Unspecified