Provider Demographics
NPI:1336131473
Name:GARDNER, MARK A (DPM)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:A
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 1:510 BUTLER AVE
Mailing Address - Street 2:
Mailing Address - City:MARTINSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:25405-9990
Mailing Address - Country:US
Mailing Address - Phone:304-263-0811
Mailing Address - Fax:800-817-3807
Practice Address - Street 1:510 BUTLER AVE
Practice Address - Street 2:
Practice Address - City:MARTINSBURG
Practice Address - State:WV
Practice Address - Zip Code:25405-9990
Practice Address - Country:US
Practice Address - Phone:304-263-0811
Practice Address - Fax:800-817-3807
Is Sole Proprietor?:No
Enumeration Date:2005-08-16
Last Update Date:2020-11-25
Deactivation Date:2006-03-22
Deactivation Code:
Reactivation Date:2006-03-27
Provider Licenses
StateLicense IDTaxonomies
VA0103000917213ES0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0000XPodiatric Medicine & Surgery Service ProvidersPodiatristSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA115888OtherANTHEM BC/BS
VA1215628OtherCIGNA
VA65326OtherSENTARA
VA5672190001Medicare NSC
U49016Medicare UPIN
VA65326OtherSENTARA