Provider Demographics
NPI:1831517242
Name:GARDNER, MICHAEL RAE (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:RAE
Last Name:GARDNER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 26666
Mailing Address - Street 2:PROVIDER ENROLLMENT
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87125-6666
Mailing Address - Country:US
Mailing Address - Phone:505-923-6770
Mailing Address - Fax:505-923-5354
Practice Address - Street 1:201 CEDAR ST SE STE 7600
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87106-4921
Practice Address - Country:US
Practice Address - Phone:505-563-2500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-02
Last Update Date:2023-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2023-1307207RC0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac Electrophysiology