Provider Demographics
NPI:1043521719
Name:CARDENAS, GABRIEL JR (DPM)
Entity type:Individual
Prefix:DR
First Name:GABRIEL
Middle Name:
Last Name:CARDENAS
Suffix:JR
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 1:521 MEADOW GLEN CT
Mailing Address - Street 2:
Mailing Address - City:HOUSE SPRINGS
Mailing Address - State:MO
Mailing Address - Zip Code:63051-4320
Mailing Address - Country:US
Mailing Address - Phone:618-514-1308
Mailing Address - Fax:
Practice Address - Street 1:6810 STATE ROUTE 162
Practice Address - Street 2:SUITE 20
Practice Address - City:MARYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62062-8587
Practice Address - Country:US
Practice Address - Phone:618-288-2835
Practice Address - Fax:618-288-6162
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-28
Last Update Date:2016-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2010021578213ES0103X
IL016.005608213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILF100153987OtherMEDICARE GROUP PTAN
ILF100153987Medicare UPIN
ILF400153992Medicare PIN