Provider Demographics
NPI:1639383599
Name:GARDNER, MICHELLE ANN (OD)
Entity Type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:ANN
Last Name:GARDNER
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:808 WACKER DR
Mailing Address - Street 2:
Mailing Address - City:DUBUQUE
Mailing Address - State:IA
Mailing Address - Zip Code:52002
Mailing Address - Country:US
Mailing Address - Phone:563-557-1133
Mailing Address - Fax:563-557-3022
Practice Address - Street 1:808 WACKER DR
Practice Address - Street 2:
Practice Address - City:DUBUQUE
Practice Address - State:IA
Practice Address - Zip Code:52002
Practice Address - Country:US
Practice Address - Phone:563-557-1133
Practice Address - Fax:563-557-3022
Is Sole Proprietor?:No
Enumeration Date:2007-05-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA02281152W00000X
IL152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0425991Medicaid
819247OtherEYEMED
36582OtherBLUE CROSS BLUE SHIELD