Provider Demographics
NPI:1326072000
Name:GARDNER, ALLEN RICHARD (MD)
Entity Type:Individual
Prefix:
First Name:ALLEN
Middle Name:RICHARD
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:PO BOX 10880
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86304-0880
Mailing Address - Country:US
Mailing Address - Phone:928-759-5987
Mailing Address - Fax:928-458-2039
Practice Address - Street 1:3120 CLEARWATER DR
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86305-7131
Practice Address - Country:US
Practice Address - Phone:928-771-3704
Practice Address - Fax:928-771-0434
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2015-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ31108207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ785701Medicaid
AZZ79796Medicare PIN
AZD14631Medicare UPIN
AZZ79796Medicare PIN