Provider Demographics
NPI:1659583888
Name:GARDINE, CYPRIAN A III (MD)
Entity Type:Individual
Prefix:MR
First Name:CYPRIAN
Middle Name:A
Last Name:GARDINE
Suffix:III
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 1:1900 44TH ST SE
Mailing Address - Street 2:
Mailing Address - City:KENTWOOD
Mailing Address - State:MI
Mailing Address - Zip Code:49508-5008
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:300 LAFAYETTE AVE SE
Practice Address - Street 2:STE 2045
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-4692
Practice Address - Country:US
Practice Address - Phone:616-685-3098
Practice Address - Fax:616-685-3095
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2021-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301106353207RE0101X
IN01063200A207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200861900Medicaid
IN146470D4Medicare PIN
INI74244Medicare UPIN