Provider Demographics
NPI:1568458701
Name:GARDNER, SCOTT ALLAN (MD)
Entity Type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:ALLAN
Last Name:GARDNER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2315 8TH ST
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-7301
Mailing Address - Country:US
Mailing Address - Phone:208-298-3093
Mailing Address - Fax:
Practice Address - Street 1:2315 8TH ST
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-7301
Practice Address - Country:US
Practice Address - Phone:208-298-9030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-22
Last Update Date:2012-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD16480208600000X
IDM9619208600000X
WAMD00046059208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR012554Medicaid
WA0212253OtherLABOR & INDUSTRY
WA1013432Medicaid
ID1568458701OtherREGENCE BLUESHIELD OF IDAHO
ID1134119OtherDMERC
ID76714OtherBLUE CROSS
WAP00815199OtherMEDICARE RR - WA
ID1568458701Medicaid
IDP00349485OtherMEDICARE -RR - IDAHO
WA0212253OtherLABOR & INDUSTRY
WAP00815199OtherMEDICARE RR - WA
ID1134119Medicare PIN