Provider Demographics
NPI:1952528366
Name:GARDNER, THOMAS A (MD)
Entity type:Individual
Prefix:
First Name:THOMAS
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 1:2801 W KINNICKINNIC RIVER PKWY STE 680
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53215-3669
Mailing Address - Country:US
Mailing Address - Phone:414-385-7111
Mailing Address - Fax:
Practice Address - Street 1:2801 W KINNICKINNIC PKWY
Practice Address - Street 2:630
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53215-5212
Practice Address - Country:US
Practice Address - Phone:414-385-7111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-19
Last Update Date:2019-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO31257207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
006976OtherKAISER-COMMERCIAL NUMBER
WI1952528366Medicaid
CO01312578Medicaid
CO01312578Medicaid
COCK10402Medicare PIN