Provider Demographics
NPI:1841249224
Name:GARDNER, TIMOTHY LOGAN (DPM)
Entity type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:LOGAN
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 1:8930 CROSS PARK DR STE 2
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37923-4713
Mailing Address - Country:US
Mailing Address - Phone:865-269-2112
Mailing Address - Fax:865-218-7475
Practice Address - Street 1:8930 CROSS PARK DR STE 2
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37923-4713
Practice Address - Country:US
Practice Address - Phone:865-218-7474
Practice Address - Fax:865-218-7475
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-10
Last Update Date:2022-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDPM 409213E00000X, 213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY80002017Medicaid
TN3351921Medicaid
KY000000053556OtherBCBS
TN0191729OtherBCBS
U18698Medicare UPIN
TN4138170001Medicare NSC
KY2012301Medicare PIN
TN0191729OtherBCBS