Provider Demographics
NPI:1811965916
Name:GARDNER, DAVID G (DPM)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:G
Last Name:GARDNER
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3101 KILPATRICK BLVD
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71201-5157
Mailing Address - Country:US
Mailing Address - Phone:318-322-5506
Mailing Address - Fax:318-322-5916
Practice Address - Street 1:3101 KILPATRICK BLVD
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201-5157
Practice Address - Country:US
Practice Address - Phone:318-322-5506
Practice Address - Fax:318-322-5916
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-14
Last Update Date:2010-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPD221R213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1484997Medicaid
LA5284340001Medicare NSC
LA5A836Medicare PIN
LAU71319Medicare UPIN