Provider Demographics
NPI:1609899293
Name:GARDNER, HENRY JERRY (MD)
Entity Type:Individual
Prefix:DR
First Name:HENRY
Middle Name:JERRY
Last Name:GARDNER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:H
Other - Middle Name:JERRY
Other - Last Name:GARDNER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:11248 N PARK DR
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND
Mailing Address - State:UT
Mailing Address - Zip Code:84003-9611
Mailing Address - Country:US
Mailing Address - Phone:801-369-7367
Mailing Address - Fax:
Practice Address - Street 1:8900 SE 165TH MULBERRY LN
Practice Address - Street 2:
Practice Address - City:THE VILLAGES
Practice Address - State:FL
Practice Address - Zip Code:32162-5884
Practice Address - Country:US
Practice Address - Phone:352-674-5000
Practice Address - Fax:352-674-5031
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2011-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1504831205207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT990177709006Medicaid
000001871Medicare PIN
UT990177709006Medicaid
D07451Medicare UPIN
005528105Medicare PIN