Provider Demographics
NPI:1770632150
Name:GARDNER, AMY (MD)
Entity Type:Individual
Prefix:DR
First Name:AMY
Middle Name:
Last Name:GARDNER
Suffix:
Gender:F
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:DEPARTMENT OF PSYCHIATRY SUNY MEDICAL CTR
Mailing Address - Street 2:HSC, T10-020
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11794-8101
Mailing Address - Country:US
Mailing Address - Phone:631-444-2884
Mailing Address - Fax:631-444-1560
Practice Address - Street 1:4549 CHAMBLEE DUNWOODY RD
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30338-6210
Practice Address - Country:US
Practice Address - Phone:770-677-9440
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-09
Last Update Date:2023-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1439282084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY96D691Medicare ID - Type Unspecified