Provider Demographics
NPI:1972571818
Name:GARDNER, JOHN C (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:C
Last Name:GARDNER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 N ACADEMY AVE
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17822-3034
Mailing Address - Country:US
Mailing Address - Phone:570-271-6144
Mailing Address - Fax:570-271-6578
Practice Address - Street 1:110 TRIEBLE RD
Practice Address - Street 2:
Practice Address - City:TUNKHANNOCK
Practice Address - State:PA
Practice Address - Zip Code:18657
Practice Address - Country:US
Practice Address - Phone:570-996-2700
Practice Address - Fax:570-996-2711
Is Sole Proprietor?:No
Enumeration Date:2006-03-08
Last Update Date:2008-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD029501E207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001008139Medicaid
C31270Medicare UPIN
PA134290Medicare ID - Type Unspecified