Provider Demographics
NPI:1396836375
Name:GARDNER, THOMAS L (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:L
Last Name:GARDNER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3340 NORTH CENTER ST #800
Mailing Address - Street 2:
Mailing Address - City:LEHI
Mailing Address - State:UT
Mailing Address - Zip Code:84043-7406
Mailing Address - Country:US
Mailing Address - Phone:801-990-1911
Mailing Address - Fax:801-990-1912
Practice Address - Street 1:1034 NORTH 500 WEST
Practice Address - Street 2:UTAH VALLEY REGIONAL MEDICAL CENTER
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604
Practice Address - Country:US
Practice Address - Phone:801-507-5248
Practice Address - Fax:801-733-5618
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2012-10-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
UT363811-1205207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT64482OtherPEHP
UT682520OtherDESERET MUTUAL
UTQM0000075886OtherALTIUS
WY118322200Medicaid
NV002082157Medicaid
UT79086OtherHEALTHY U
ID806156600Medicaid
UT870545614GAROtherEDUCATORS MUTUAL
UT107008344102OtherIHC
UT36381112001001OtherBCBS
AZ772659Medicaid
UTPRA05966OtherMOLINA
UT1502954OtherUMWA
UTPRA05966OtherMOLINA
UT870545614GAROtherEDUCATORS MUTUAL
UT79086OtherHEALTHY U