Provider Demographics
NPI:1235282252
Name:GARDNER, PHILIP LEO (MD)
Entity type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:LEO
Last Name:GARDNER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:2241 CENTRAL AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:ALAMEDA
Mailing Address - State:CA
Mailing Address - Zip Code:94501-4460
Mailing Address - Country:US
Mailing Address - Phone:510-522-0377
Mailing Address - Fax:510-522-5372
Practice Address - Street 1:2241 CENTRAL AVE
Practice Address - Street 2:SUITE A
Practice Address - City:ALAMEDA
Practice Address - State:CA
Practice Address - Zip Code:94501-4460
Practice Address - Country:US
Practice Address - Phone:510-522-0377
Practice Address - Fax:510-522-5372
Is Sole Proprietor?:No
Enumeration Date:2007-01-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA22059207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A220590Medicaid
CA00A220590Medicaid
CA00A220590Medicare ID - Type Unspecified