Provider Demographics
NPI:1417140070
Name:TIMOTHY L. GARDNER,DPM
Entity Type:Organization
Organization Name:TIMOTHY L. GARDNER,DPM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:LOGAN
Authorized Official - Last Name:GARDNER
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:865-218-7474
Mailing Address - Street 1:10810 PARKSIDE DR STE 202
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37934-1981
Mailing Address - Country:US
Mailing Address - Phone:865-218-7474
Mailing Address - Fax:865-218-7475
Practice Address - Street 1:10810 PARKSIDE DR STE 202
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37934-1981
Practice Address - Country:US
Practice Address - Phone:865-218-7474
Practice Address - Fax:865-218-7475
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-27
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDPM409213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3351921Medicaid
TN0191729OtherBCBS
TN3351921Medicaid
TN3351921Medicare PIN