Provider Demographics
NPI:1295731990
Name:GARDNER, STEVEN EDWARD (MD)
Entity type:Individual
Prefix:
First Name:STEVEN
Middle Name:EDWARD
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 1:2020 GENESEE AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-4219
Mailing Address - Country:US
Mailing Address - Phone:858-616-8091
Mailing Address - Fax:858-616-8090
Practice Address - Street 1:2020 GENESEE AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-4219
Practice Address - Country:US
Practice Address - Phone:858-616-8091
Practice Address - Fax:858-616-8090
Is Sole Proprietor?:No
Enumeration Date:2005-06-27
Last Update Date:2014-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG53689207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G53689Medicaid
CAE89840Medicare UPIN
CAG53689Medicare ID - Type Unspecified