Provider Demographics
NPI:1306836622
Name:GARDNER, DAN ROBERT (MD)
Entity Type:Individual
Prefix:
First Name:DAN
Middle Name:ROBERT
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 1:725 HIGHLAND OAKS DR
Mailing Address - Street 2:SUITE 101
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-7109
Mailing Address - Country:US
Mailing Address - Phone:336-659-8180
Mailing Address - Fax:336-659-8363
Practice Address - Street 1:725 HIGHLAND OAKS DR
Practice Address - Street 2:SUITE 101
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-7109
Practice Address - Country:US
Practice Address - Phone:336-659-8180
Practice Address - Fax:336-659-8363
Is Sole Proprietor?:No
Enumeration Date:2005-10-27
Last Update Date:2009-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC4332207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR102198001Medicaid
D04555Medicare UPIN
AR51813Medicare ID - Type Unspecified