Provider Demographics
NPI:1336465566
Name:GARDINER, JEFFREY PAUL (DO)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:PAUL
Last Name:GARDINER
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 1:1055 N 300 W
Mailing Address - Street 2:SUITE 204
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-3344
Mailing Address - Country:US
Mailing Address - Phone:801-357-7373
Mailing Address - Fax:801-357-7217
Practice Address - Street 1:1055 N 300 W
Practice Address - Street 2:SUITE 204
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-3344
Practice Address - Country:US
Practice Address - Phone:801-357-7373
Practice Address - Fax:801-357-7217
Is Sole Proprietor?:No
Enumeration Date:2010-04-13
Last Update Date:2020-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34011221207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTU000091357Medicare PIN
OH0105674Medicaid