Provider Demographics
NPI:1477514370
Name:GARDNER, DAVID A (DPM)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:A
Last Name:GARDNER
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1441 SOUTH MIDLOTHIAN PKWY
Mailing Address - Street 2:STE 120
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:TX
Mailing Address - Zip Code:76065-5592
Mailing Address - Country:US
Mailing Address - Phone:972-775-8553
Mailing Address - Fax:972-775-8554
Practice Address - Street 1:1441 SOUTH MIDLOTHIAN PKWY
Practice Address - Street 2:STE 120
Practice Address - City:MIDLOTHIAN
Practice Address - State:TX
Practice Address - Zip Code:76065-5592
Practice Address - Country:US
Practice Address - Phone:972-775-8553
Practice Address - Fax:972-775-8554
Is Sole Proprietor?:No
Enumeration Date:2006-03-30
Last Update Date:2011-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1433213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX153605402Medicaid
5781990001Medicare NSC
TX8F8558Medicare PIN
U75767Medicare UPIN
TX153605402Medicaid