Provider Demographics
NPI:1497797450
Name:GARDNER, FREDERICK (DC)
Entity Type:Individual
Prefix:MR
First Name:FREDERICK
Middle Name:
Last Name:GARDNER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8402 OSWEGO RD
Mailing Address - Street 2:
Mailing Address - City:LIVERPOOL
Mailing Address - State:NY
Mailing Address - Zip Code:13090-1004
Mailing Address - Country:US
Mailing Address - Phone:315-622-0102
Mailing Address - Fax:315-622-0112
Practice Address - Street 1:8402 OSWEGO RD
Practice Address - Street 2:
Practice Address - City:LIVERPOOL
Practice Address - State:NY
Practice Address - Zip Code:13090-1004
Practice Address - Country:US
Practice Address - Phone:315-622-0102
Practice Address - Fax:315-622-0112
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-12
Last Update Date:2012-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX009506-1111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYCO95069OtherWORKERS' COMPENSATION
NYCO95069OtherWORKERS' COMPENSATION