Provider Demographics
NPI:1811921174
Name:GARDNER, MARK L (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:L
Last Name:GARDNER
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 1:475 N FORBES ST
Mailing Address - Street 2:
Mailing Address - City:LAKEPORT
Mailing Address - State:CA
Mailing Address - Zip Code:95453-4725
Mailing Address - Country:US
Mailing Address - Phone:707-263-6346
Mailing Address - Fax:707-263-5327
Practice Address - Street 1:475 N FORBES ST
Practice Address - Street 2:
Practice Address - City:LAKEPORT
Practice Address - State:CA
Practice Address - Zip Code:95453-4725
Practice Address - Country:US
Practice Address - Phone:707-263-6346
Practice Address - Fax:707-263-5327
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2017-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0065785207RC0000X
CAG73337207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLF40095Medicare UPIN
FL23917OtherBC/BS FLORIDA
FL23917YMedicare ID - Type Unspecified
FL6014266OtherGHI