MEDICARE: DR. MICHAEL GARDNER D.O.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	0102203325	VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1336299122
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MICHAEL GARDNER D.O.

Provider Business Mailing Address
First Line	:	1540 BREEZEPORT WAY STE 100
Second Line	:
City	:	SUFFOLK
State	:	VA
Zip	:	23435-3752
Country	:	US
Telephone Number	:	757-538-7275
Fax Number	:	757-335-7230

Provider Business Practice Location Address
First Line	:	1540 BREEZEPORT WAY STE 100
Second Line	:
City	:	SUFFOLK
State	:	VA
Zip	:	23435-3752
Country	:	US
Telephone Number	:	757-538-7275
Fax Number	:	757-335-7230

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/12/2007
Last Update Date	:	03/04/2026

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