Provider Demographics
NPI:1366470544
Name:GARDON, MARK A (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:GARDON
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 1:2845 GREENBRIER RD STE 330
Mailing Address - Street 2:PO BOX 8900
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54308-8900
Mailing Address - Country:US
Mailing Address - Phone:920-288-8350
Mailing Address - Fax:920-288-8355
Practice Address - Street 1:2845 GREENBRIER RD STE 330
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54311-6519
Practice Address - Country:US
Practice Address - Phone:920-288-8350
Practice Address - Fax:920-288-8355
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2021-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI32288207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI104405670Medicaid
MI104806220Medicaid
WI140007796OtherRAILROAD
WI34201700Medicaid
MI104584884Medicaid
MI104584884Medicaid
WI002971460Medicare ID - Type Unspecified
MI104405670Medicaid