Provider Demographics
NPI:1770826299
Name:GARDNER, JOHN ANTHONY II
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:ANTHONY
Last Name:GARDNER
Suffix:II
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 21890
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-4115
Mailing Address - Country:US
Mailing Address - Phone:270-745-7246
Mailing Address - Fax:270-282-2027
Practice Address - Street 1:1112 S MAIN ST STE 7
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:KY
Practice Address - Zip Code:42134-2322
Practice Address - Country:US
Practice Address - Phone:270-745-7246
Practice Address - Fax:270-282-2027
Is Sole Proprietor?:No
Enumeration Date:2013-04-03
Last Update Date:2024-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH57.022765207L00000X
KY51044207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100538630Medicaid