Provider Demographics
NPI:1508855826
Name:GARDNER, SERITA MARIE (OD)
Entity Type:Individual
Prefix:DR
First Name:SERITA
Middle Name:MARIE
Last Name:GARDNER
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2945 GULF FWY S
Mailing Address - Street 2:SUITE C
Mailing Address - City:LEAGUE CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77573-6770
Mailing Address - Country:US
Mailing Address - Phone:281-309-9700
Mailing Address - Fax:281-309-9720
Practice Address - Street 1:2945 GULF FWY S
Practice Address - Street 2:SUITE C
Practice Address - City:LEAGUE CITY
Practice Address - State:TX
Practice Address - Zip Code:77573-6770
Practice Address - Country:US
Practice Address - Phone:281-309-9700
Practice Address - Fax:281-309-9720
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX4258T152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXU03112Medicare UPIN