Provider Demographics
NPI:1952375487
Name:GARDNER, PHILIP A (MD)
Entity Type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:A
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 1:101 JUDGE TANNER BLVD STE 300
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:LA
Mailing Address - Zip Code:70433-7506
Mailing Address - Country:US
Mailing Address - Phone:985-867-2128
Mailing Address - Fax:985-871-1548
Practice Address - Street 1:101 JUDGE TANNER BLVD STE 300
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:LA
Practice Address - Zip Code:70433-7506
Practice Address - Country:US
Practice Address - Phone:985-867-2128
Practice Address - Fax:985-871-1548
Is Sole Proprietor?:No
Enumeration Date:2006-02-13
Last Update Date:2023-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA03988R2086S0129X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1319210Medicaid
LA1952375487Medicaid
LA8641OtherLA DHH CONTROLED SUBST
LA03988ROtherMEDICAL LICENSE
LA1319210Medicaid
LA03988ROtherMEDICAL LICENSE