Healthcare Provider Details

I. General information

NPI: 1629084710
Provider Name (Legal Business Name): MATTHEW J GARDINER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2006
Last Update Date: 01/31/2025
Certification Date: 01/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

299 12TH ST
MARINA CA
93933-6003
US

IV. Provider business mailing address

6672 SERVICEBERRY DR
PARK CITY UT
84098-1518
US

V. Phone/Fax

Practice location:
  • Phone: 831-647-7652
  • Fax:
Mailing address:
  • Phone: 801-510-2543
  • Fax: 801-614-7067

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number475067-1205
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberC159653
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: