Provider Demographics
NPI:1861482465
Name:GARDNER, TIMOTHY LEE (MD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
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 1:1009 N STATE OF FRANKLIN ACCESS RD
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-3693
Mailing Address - Country:US
Mailing Address - Phone:423-929-7546
Mailing Address - Fax:423-929-7968
Practice Address - Street 1:1009 N STATE OF FRANKLIN ACCESS RD
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-3693
Practice Address - Country:US
Practice Address - Phone:423-929-7546
Practice Address - Fax:423-929-7968
Is Sole Proprietor?:No
Enumeration Date:2005-10-25
Last Update Date:2009-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN38003207N00000X, 207ND0900X, 207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNI03402Medicare UPIN
TN3893938Medicare ID - Type Unspecified