Provider Demographics
NPI:1790897452
Name:GARDNER, KEVIN LEE (MD)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:LEE
Last Name:GARDNER
Suffix:
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 1:1580 W ANTELOPE DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:LAYTON
Mailing Address - State:UT
Mailing Address - Zip Code:84041-1160
Mailing Address - Country:US
Mailing Address - Phone:801-773-4770
Mailing Address - Fax:801-773-4776
Practice Address - Street 1:1580 W ANTELOPE DR
Practice Address - Street 2:SUITE 200
Practice Address - City:LAYTON
Practice Address - State:UT
Practice Address - Zip Code:84041-1160
Practice Address - Country:US
Practice Address - Phone:801-773-4770
Practice Address - Fax:801-773-4776
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2016-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT23267021205207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
H18138Medicare UPIN
UT005581403Medicare ID - Type Unspecified