Provider Demographics
NPI:1891173811
Name:GARDNER, MARYN VIRGINIA (MD)
Entity Type:Individual
Prefix:DR
First Name:MARYN
Middle Name:VIRGINIA
Last Name:GARDNER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1120 W MICHIGAN ST RM 626
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46202-5209
Mailing Address - Country:US
Mailing Address - Phone:317-278-2686
Mailing Address - Fax:317-278-2650
Practice Address - Street 1:1120 W MICHIGAN ST RM 626
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-5209
Practice Address - Country:US
Practice Address - Phone:317-278-2686
Practice Address - Fax:317-278-2650
Is Sole Proprietor?:No
Enumeration Date:2015-05-11
Last Update Date:2015-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN11018088A390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN11018088AOtherMEDICAL RESIDENCY PERMIT