Healthcare Provider Details

I. General information

NPI: 1407242373
Provider Name (Legal Business Name): KEVIN GARDNER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/08/2015
Last Update Date: 06/18/2024
Certification Date: 06/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1411 E 31ST ST
OAKLAND CA
94602-1018
US

IV. Provider business mailing address

1411 E 31ST ST
OAKLAND CA
94602-1092
US

V. Phone/Fax

Practice location:
  • Phone: 510-437-8356
  • Fax:
Mailing address:
  • Phone: 510-437-4800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number147618
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number70723
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: