Provider Demographics
NPI:1376554147
Name:GARDNER, MELISSA DEANN (OD)
Entity Type:Individual
Prefix:DR
First Name:MELISSA
Middle Name:DEANN
Last Name:GARDNER
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1507 NW 79TH TER
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64118-6490
Mailing Address - Country:US
Mailing Address - Phone:816-804-6336
Mailing Address - Fax:
Practice Address - Street 1:5744 ANTIOCH RD
Practice Address - Street 2:
Practice Address - City:MERRIAM
Practice Address - State:KS
Practice Address - Zip Code:66202-2015
Practice Address - Country:US
Practice Address - Phone:913-362-9131
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1507152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KST84E400Medicare UPIN