Provider Demographics
NPI:1578528097
Name:GARDNER, LAWRENCE D (MD)
Entity Type:Individual
Prefix:DR
First Name:LAWRENCE
Middle Name:D
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 1:2337 PROMETHEUS CT
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89074-5339
Mailing Address - Country:US
Mailing Address - Phone:702-433-1804
Mailing Address - Fax:
Practice Address - Street 1:2337 PROMETHEUS CT
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89074-5339
Practice Address - Country:US
Practice Address - Phone:702-433-1804
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-18
Last Update Date:2015-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVNV2962208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV002002166Medicaid
NV002002166Medicaid
NVV103265Medicare PIN