Provider Demographics
NPI:1780687137
Name:GARDNER, ROBERT R (DO)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:R
Last Name:GARDNER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6542 SANDPEBBLE CT
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:45322-3626
Mailing Address - Country:US
Mailing Address - Phone:937-832-1862
Mailing Address - Fax:937-656-1347
Practice Address - Street 1:6542 SANDPEBBLE CT
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:OH
Practice Address - Zip Code:45322-3626
Practice Address - Country:US
Practice Address - Phone:937-832-1862
Practice Address - Fax:937-656-1347
Is Sole Proprietor?:No
Enumeration Date:2005-05-31
Last Update Date:2018-03-17
Deactivation Date:2017-03-23
Deactivation Code:
Reactivation Date:2018-03-17
Provider Licenses
StateLicense IDTaxonomies
OH34003219G207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0500765Medicaid
OH34003219OtherMEDICAL LICENSE
OH642249OtherAETNA
OHD0321904OtherHUMANA/CHOICECARE
OH000000390155OtherANTHEM
OH0122480OtherUNITED HEALTHCARE
OH24754OtherNATIONWIDE HEALTH PLAN
OH080191717OtherRAILROAD MEDICARE
OH421534506032OtherCARESOURCE
OH000000390155OtherUNICARE
OH0122480OtherUNITED HEALTHCARE
OH0500765Medicare UPIN