Healthcare Provider Details

I. General information

NPI: 1023183829
Provider Name (Legal Business Name): ROBERT WILLIAM GARDNER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/21/2006
Last Update Date: 11/01/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6300 E. HWY 20
LUCERNE CA
95458
US

IV. Provider business mailing address

10458 CHATTEN COURT
CLEARLAKE OAKS CA
95423-7050
US

V. Phone/Fax

Practice location:
  • Phone: 707-274-9299
  • Fax: 707-274-9297
Mailing address:
  • Phone: 707-274-9299
  • Fax: 707-274-9297

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License NumberG30366
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: