Provider Demographics
NPI:1851381420
Name:GARDNER, RICHARD CHARLES (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:CHARLES
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 1:77 MASSACHUSETTS AVE
Mailing Address - Street 2:E23-268
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02139-4301
Mailing Address - Country:US
Mailing Address - Phone:617-253-4988
Mailing Address - Fax:617-253-4988
Practice Address - Street 1:77 MASS AVE
Practice Address - Street 2:MIT MEDICAL DEPT RM 23 215
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02139-4301
Practice Address - Country:US
Practice Address - Phone:617-253-1681
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-25
Last Update Date:2012-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA29590207R00000X, 207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0130745Medicaid
B75668Medicare UPIN
MA0130745Medicaid