Provider Demographics
NPI:1831355775
Name:GARDNER, JAMES CALEB (OD)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:CALEB
Last Name:GARDNER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:J.
Other - Middle Name:CALEB
Other - Last Name:GARDNER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:PO BOX 856
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:36037-0856
Mailing Address - Country:US
Mailing Address - Phone:334-382-5571
Mailing Address - Fax:
Practice Address - Street 1:846 FORT DALE RD
Practice Address - Street 2:STE A
Practice Address - City:GREENVILLE
Practice Address - State:AL
Practice Address - Zip Code:36037-3509
Practice Address - Country:US
Practice Address - Phone:334-382-5571
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-30
Last Update Date:2010-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALS-B80-TA-787152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL6256000002Medicare NSC