Provider Demographics
NPI:1639490386
Name:GARDNER, KEVIN HALL (DO)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:HALL
Last Name:GARDNER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1055 N 500 W
Mailing Address - Street 2:ATTN: CREDENTIALING
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-3305
Mailing Address - Country:US
Mailing Address - Phone:801-374-8999
Mailing Address - Fax:801-429-8063
Practice Address - Street 1:1055 N 500 W
Practice Address - Street 2:STE 111
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-3305
Practice Address - Country:US
Practice Address - Phone:801-374-8999
Practice Address - Fax:801-429-8063
Is Sole Proprietor?:No
Enumeration Date:2010-06-17
Last Update Date:2021-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
UT9332631-1204207N00000X, 207ND0101X
MN54109207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAENROLLEDMedicaid
MNENROLLEDMedicaid
MN070000952Medicare PIN
MNP01071117OtherRAILROAD MEDICARE