Provider Demographics
NPI:1770010118
Name:GARDNER, RUBY (DPM)
Entity Type:Individual
Prefix:
First Name:RUBY
Middle Name:
Last Name:GARDNER
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 N CLOVER DR
Mailing Address - Street 2:
Mailing Address - City:GREAT NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11021-1038
Mailing Address - Country:US
Mailing Address - Phone:310-801-7893
Mailing Address - Fax:
Practice Address - Street 1:24 N CLOVER DR
Practice Address - Street 2:
Practice Address - City:GREAT NECK
Practice Address - State:NY
Practice Address - Zip Code:11021-1038
Practice Address - Country:US
Practice Address - Phone:310-801-7893
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-16
Last Update Date:2023-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
133N00000X, 390200000X
NYN007041213E00000X, 213EP0504X, 213EP1101X, 213ER0200X, 213ES0000X, 213ES0131X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No133N00000XDietary & Nutritional Service ProvidersNutritionist
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213EP0504XPodiatric Medicine & Surgery Service ProvidersPodiatristPublic Medicine
No213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
No213ER0200XPodiatric Medicine & Surgery Service ProvidersPodiatristRadiology
No213ES0000XPodiatric Medicine & Surgery Service ProvidersPodiatristSports Medicine
No213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program