Provider Demographics
NPI:1881763670
Name:GARDNER, CHARLES WILLIAM JR (MD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:WILLIAM
Last Name:GARDNER
Suffix:JR
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 1:4401 FORD AVE
Mailing Address - Street 2:SUITE 250
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22302-1473
Mailing Address - Country:US
Mailing Address - Phone:703-647-4962
Mailing Address - Fax:703-379-5380
Practice Address - Street 1:4401 FORD AVE
Practice Address - Street 2:SUITE 250
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22302-1473
Practice Address - Country:US
Practice Address - Phone:703-647-4962
Practice Address - Fax:703-379-5380
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2010-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101033882207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00126329OtherRAILROAD MEDICARE
C47159Medicare UPIN
489677N07Medicare PIN