Provider Demographics
NPI:1952303828
Name:GARDNER, BRETT L (MD)
Entity Type:Individual
Prefix:
First Name:BRETT
Middle Name:L
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 1:2107 HEIGHTS DR
Mailing Address - Street 2:
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54701-6130
Mailing Address - Country:US
Mailing Address - Phone:715-834-8721
Mailing Address - Fax:715-834-3087
Practice Address - Street 1:1221 WHIPPLE ST
Practice Address - Street 2:
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54703-5270
Practice Address - Country:US
Practice Address - Phone:715-838-3311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-11
Last Update Date:2014-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI21688207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30320400Medicaid
WI30320400Medicaid
B52988Medicare UPIN