Provider Demographics
NPI:1386866176
Name:GARDNER, CAROL QUILLIGAN (MD)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:QUILLIGAN
Last Name:GARDNER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 HARVEY CT
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92617-4033
Mailing Address - Country:US
Mailing Address - Phone:949-854-2803
Mailing Address - Fax:949-856-0127
Practice Address - Street 1:2646 DUPONT DR
Practice Address - Street 2:SUITE 250
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92612-8887
Practice Address - Country:US
Practice Address - Phone:949-261-2981
Practice Address - Fax:949-261-8292
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG727022080A0000X
CA261QC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Not Answered261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health