Provider Demographics
NPI:1336299122
Name:GARDNER, MICHAEL (DO)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:GARDNER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:633D AIR BASE WING, FAMILY HEALTH CLINIC
Mailing Address - Street 2:77 NEALY DRIVE
Mailing Address - City:LANGLEY AFB
Mailing Address - State:VA
Mailing Address - Zip Code:23665
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:633D AIR BASE WING, FAMILY HEALTH CLINIC
Practice Address - Street 2:77 NEALY DRIVE
Practice Address - City:LANGLEY AFB
Practice Address - State:VA
Practice Address - Zip Code:23665
Practice Address - Country:US
Practice Address - Phone:757-225-7630
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-12
Last Update Date:2023-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0102203325207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1336299122Medicaid