Provider Demographics
NPI:1295953743
Name:GARDINER HASSARD, TANIA COY (OD)
Entity type:Individual
Prefix:
First Name:TANIA
Middle Name:COY
Last Name:GARDINER HASSARD
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:TANIA
Other - Middle Name:COY
Other - Last Name:GARDINER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:30 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:ME
Mailing Address - Zip Code:04937-1120
Mailing Address - Country:US
Mailing Address - Phone:207-453-6811
Mailing Address - Fax:
Practice Address - Street 1:30 MAIN ST
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:ME
Practice Address - Zip Code:04937-1120
Practice Address - Country:US
Practice Address - Phone:207-453-6811
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-22
Last Update Date:2014-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEOPT863152W00000X
MEPR4842183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEMM9608Medicare PIN