Provider Demographics
NPI:1750354783
Name:GARDNER, MARSHALL KEITH (DO)
Entity type:Individual
Prefix:DR
First Name:MARSHALL
Middle Name:KEITH
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 1:15 ANTHONY DR
Mailing Address - Street 2:
Mailing Address - City:RICHBORO
Mailing Address - State:PA
Mailing Address - Zip Code:18954-1328
Mailing Address - Country:US
Mailing Address - Phone:215-969-3013
Mailing Address - Fax:215-676-2522
Practice Address - Street 1:10151 BUSTLETON AVE
Practice Address - Street 2:# D
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19116-3718
Practice Address - Country:US
Practice Address - Phone:215-969-3013
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-09
Last Update Date:2016-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS003214L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAC29324Medicare UPIN
PA083453Medicare ID - Type Unspecified