Provider Demographics
NPI:1457315004
Name:GARDNER, PAMELA R (DO)
Entity Type:Individual
Prefix:DR
First Name:PAMELA
Middle Name:R
Last Name:GARDNER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1001 BELLEFONTAINE AVE
Mailing Address - Street 2:
Mailing Address - City:LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:45804-2800
Mailing Address - Country:US
Mailing Address - Phone:419-998-4575
Mailing Address - Fax:419-998-4586
Practice Address - Street 1:1003 BELLEFONTAINE AVE STE 200
Practice Address - Street 2:
Practice Address - City:LIMA
Practice Address - State:OH
Practice Address - Zip Code:45804-1803
Practice Address - Country:US
Practice Address - Phone:419-224-5915
Practice Address - Fax:419-224-5918
Is Sole Proprietor?:No
Enumeration Date:2006-04-12
Last Update Date:2021-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34008055207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2414515Medicaid
OH2414515Medicaid
P00060919OtherRR MEDICARE
OH2414515Medicaid
OH2414515Medicaid