Provider Demographics
NPI:1336157585
Name:GARDNER, DEL R (DO)
Entity Type:Individual
Prefix:
First Name:DEL
Middle Name:R
Last Name:GARDNER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9010 W CHEYENNE AVE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89129-8932
Mailing Address - Country:US
Mailing Address - Phone:702-240-8646
Mailing Address - Fax:702-240-0206
Practice Address - Street 1:4845 S RAINBOW BLVD STE 402
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89103-4750
Practice Address - Country:US
Practice Address - Phone:702-362-9800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2022-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVDO1834207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN00000079452OtherANTHEM, BCBS
NV100544217Medicaid
INF38126Medicare UPIN
IN151020ZZZMedicare PIN