Provider Demographics
NPI:1396040838
Name:GARDNER, JERRY D (MD)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:D
Last Name:GARDNER
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 1:75 DESILVA ISLAND DRIVE
Mailing Address - Street 2:
Mailing Address - City:MILL VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:94941
Mailing Address - Country:US
Mailing Address - Phone:415-381-1041
Mailing Address - Fax:415-381-1046
Practice Address - Street 1:75 DESILVA ISLAND DRIVE
Practice Address - Street 2:
Practice Address - City:MILL VALLEY
Practice Address - State:CA
Practice Address - Zip Code:94941
Practice Address - Country:US
Practice Address - Phone:415-381-1041
Practice Address - Fax:415-381-1046
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-13
Last Update Date:2011-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD009630E207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine