Provider Demographics
NPI:1346358769
Name:GARDNER, KEVIN M (OD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:M
Last Name:GARDNER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1701 W 26TH ST STE E
Mailing Address - Street 2:
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64804-1513
Mailing Address - Country:US
Mailing Address - Phone:417-952-2366
Mailing Address - Fax:
Practice Address - Street 1:1531 W 32ND STREET
Practice Address - Street 2:SUITE 102
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64804-1651
Practice Address - Country:US
Practice Address - Phone:417-781-3630
Practice Address - Fax:417-781-9814
Is Sole Proprietor?:No
Enumeration Date:2006-08-27
Last Update Date:2023-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2653152W00000X
MOTO3487152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U27729Medicare UPIN
MO114640002Medicare PIN