Provider Demographics
NPI:1740288448
Name:GARDINER, RICHARD (MD)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:GARDINER
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:PO BOX 25
Mailing Address - Street 2:
Mailing Address - City:POTTER VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95469-0025
Mailing Address - Country:US
Mailing Address - Phone:707-743-2340
Mailing Address - Fax:
Practice Address - Street 1:11781 EAST RD
Practice Address - Street 2:
Practice Address - City:POTTER VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95469
Practice Address - Country:US
Practice Address - Phone:707-743-2340
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-07
Last Update Date:2010-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG-141072084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA39174Medicare UPIN