Provider Demographics
NPI:1508859703
Name:GARDNER, MARY S (MD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:S
Last Name:GARDNER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:46 4TH ST SW
Mailing Address - Street 2:
Mailing Address - City:WINTER HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:33880-2910
Mailing Address - Country:US
Mailing Address - Phone:863-294-2559
Mailing Address - Fax:863-293-1427
Practice Address - Street 1:171 WEBB DR
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:FL
Practice Address - Zip Code:33837-3944
Practice Address - Country:US
Practice Address - Phone:863-421-7276
Practice Address - Fax:863-421-7109
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-24
Last Update Date:2012-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME591972085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL12131OtherBLUE CROSS BLUE SHIELD
FL053313100Medicaid
FL053313100Medicaid
FL12131OtherBLUE CROSS BLUE SHIELD