Provider Demographics
NPI:1740382480
Name:GARDNER, MARION LEE JR (MD)
Entity Type:Individual
Prefix:
First Name:MARION
Middle Name:LEE
Last Name:GARDNER
Suffix:JR
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 1:10245 NW GLENCOE RD
Mailing Address - Street 2:
Mailing Address - City:NORTH PLAINS
Mailing Address - State:OR
Mailing Address - Zip Code:97133
Mailing Address - Country:US
Mailing Address - Phone:503-647-9261
Mailing Address - Fax:503-647-1230
Practice Address - Street 1:10245 NW GLENCOE RD
Practice Address - Street 2:
Practice Address - City:NORTH PLAINS
Practice Address - State:OR
Practice Address - Zip Code:97133
Practice Address - Country:US
Practice Address - Phone:503-647-9261
Practice Address - Fax:503-647-1230
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-02
Last Update Date:2013-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD17617207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR044292Medicaid
F25605Medicare UPIN
OR106844Medicare ID - Type Unspecified