Provider Demographics
NPI:1821127093
Name:GARDNER, PETER THOMAS (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:THOMAS
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:PO BOX 12197
Mailing Address - Street 2:DEPT
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38308-0136
Mailing Address - Country:US
Mailing Address - Phone:731-984-8400
Mailing Address - Fax:731-984-8305
Practice Address - Street 1:2075 PLEASANT PLAINS EXT RD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38305-6087
Practice Address - Country:US
Practice Address - Phone:731-984-8400
Practice Address - Fax:731-984-8305
Is Sole Proprietor?:No
Enumeration Date:2007-03-05
Last Update Date:2011-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN26391390200000X
TNMD26391208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program