Provider Demographics
NPI:1922050483
Name:GARDNER, ANGELA E (OD)
Entity Type:Individual
Prefix:DR
First Name:ANGELA
Middle Name:E
Last Name:GARDNER
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1224 STATE ROUTE 29
Mailing Address - Street 2:
Mailing Address - City:GREENWICH
Mailing Address - State:NY
Mailing Address - Zip Code:12834-6120
Mailing Address - Country:US
Mailing Address - Phone:518-692-2040
Mailing Address - Fax:518-692-2440
Practice Address - Street 1:1224 STATE ROUTE 29
Practice Address - Street 2:
Practice Address - City:GREENWICH
Practice Address - State:NY
Practice Address - Zip Code:12834-6120
Practice Address - Country:US
Practice Address - Phone:518-692-2040
Practice Address - Fax:518-692-2440
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2019-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005918152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY784431OtherMVP
NY000493529005OtherBSNENY
NY10032211OtherCDPHP
NYC2T601OtherEMPIRE BC
NYC2T601OtherEMPIRE BC
NY784431OtherMVP