Provider Demographics
NPI:1679848766
Name:GARDNER, JAMES MICHAEL JR
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:MICHAEL
Last Name:GARDNER
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:JIM
Other - Middle Name:MICHAEL
Other - Last Name:GARDNER
Other - Suffix:JR
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:500 UNIVERSITY BLVD STE 208
Mailing Address - Street 2:
Mailing Address - City:JUPITER
Mailing Address - State:FL
Mailing Address - Zip Code:33458-2775
Mailing Address - Country:US
Mailing Address - Phone:561-627-3130
Mailing Address - Fax:561-627-8971
Practice Address - Street 1:500 UNIVERSITY BLVD STE 208
Practice Address - Street 2:
Practice Address - City:JUPITER
Practice Address - State:FL
Practice Address - Zip Code:33458-2775
Practice Address - Country:US
Practice Address - Phone:561-627-3130
Practice Address - Fax:561-627-8971
Is Sole Proprietor?:No
Enumeration Date:2012-03-21
Last Update Date:2018-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02004702A207R00000X, 208M00000X
390200000X
FLOS15445207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201349680Medicaid