Provider Demographics
NPI:1932107489
Name:GARDNER, RAYMOND JOHN (MD)
Entity Type:Individual
Prefix:DR
First Name:RAYMOND
Middle Name:JOHN
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 1:1069 DELAWARE AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:MARION
Mailing Address - State:OH
Mailing Address - Zip Code:43302-1400
Mailing Address - Country:US
Mailing Address - Phone:740-223-3496
Mailing Address - Fax:
Practice Address - Street 1:1069 DELAWARE AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:MARION
Practice Address - State:OH
Practice Address - Zip Code:43302-1400
Practice Address - Country:US
Practice Address - Phone:740-223-3496
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-08
Last Update Date:2011-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-045970207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0497627Medicaid
OH080174017Medicare ID - Type UnspecifiedMEDICARE RAILROAD NUMBER
OHB77569Medicare UPIN
OH0497627Medicaid