Provider Demographics
NPI:1881702355
Name:GARDNER, KENT ERIC (MD)
Entity type:Individual
Prefix:DR
First Name:KENT
Middle Name:ERIC
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 1:1490 E FOREMASTER DR
Mailing Address - Street 2:SUITE 350
Mailing Address - City:ST GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84790-4488
Mailing Address - Country:US
Mailing Address - Phone:435-628-3334
Mailing Address - Fax:435-628-3375
Practice Address - Street 1:1490 E FOREMASTER DR
Practice Address - Street 2:SUITE 350
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84790-4488
Practice Address - Country:US
Practice Address - Phone:435-628-3334
Practice Address - Fax:435-628-3375
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-26
Last Update Date:2014-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT371391-1205207YS0123X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YS0123XAllopathic & Osteopathic PhysiciansOtolaryngologyFacial Plastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000012148Medicare ID - Type Unspecified
UTF87361Medicare UPIN