Provider Demographics
NPI:1962476358
Name:GARDNER, VINCENT WAYNE (MD)
Entity Type:Individual
Prefix:
First Name:VINCENT
Middle Name:WAYNE
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 1:1405 COWART ST
Mailing Address - Street 2:SUITE 321
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37408-1127
Mailing Address - Country:US
Mailing Address - Phone:423-551-8346
Mailing Address - Fax:423-551-8347
Practice Address - Street 1:1405 COWART ST
Practice Address - Street 2:SUITE 321
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37408-1127
Practice Address - Country:US
Practice Address - Phone:423-551-8346
Practice Address - Fax:423-551-8347
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-14
Last Update Date:2016-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN46227202K00000X, 208600000X
GA061073202K00000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes202K00000XAllopathic & Osteopathic PhysiciansPhlebology
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL17-10632OtherUHC
AL515-14969OtherBLUE CROSS OF ALABAMA
ALH81357Medicare UPIN
AL63-1132437OtherTRICARE
AL7875649OtherAETNA
AL051553453Medicare ID - Type Unspecified
AL529601260Medicaid
AL63-1132437OtherMOST COMMERCIALS
ALH81357OtherHEALTHSPRING