Provider Demographics
NPI:1629040597
Name:GARDNER, CAROL C (MD)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:C
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 1:2445 LANE PARK RD
Mailing Address - Street 2:
Mailing Address - City:TAVARES
Mailing Address - State:FL
Mailing Address - Zip Code:32778-9648
Mailing Address - Country:US
Mailing Address - Phone:352-343-1341
Mailing Address - Fax:
Practice Address - Street 1:9400 TURKEY LAKE RD
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32819-8001
Practice Address - Country:US
Practice Address - Phone:407-351-8500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-06
Last Update Date:2019-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME86611208M00000X, 207RH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL57888ZMedicare PIN
G98853Medicare UPIN
FL266263900Medicaid