Healthcare Provider Details

I. General information

NPI: 1205178712
Provider Name (Legal Business Name): MICHAEL ALEXANDER GARDINER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: MICHAEL ALEXANDER BRYANT-GARDINER

II. Dates (important events)

Enumeration Date: 03/22/2013
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3020 CHILDRENS WAY
SAN DIEGO CA
92123-4223
US

IV. Provider business mailing address

3020 CHILDRENS WAY # MC5003
SAN DIEGO CA
92123-4223
US

V. Phone/Fax

Practice location:
  • Phone: 858-966-8036
  • Fax:
Mailing address:
  • Phone: 858-309-6300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberQ0754
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA124399
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code2080P0204X
TaxonomyPediatric Emergency Medicine (Pediatrics) Physician
License NumberA124399
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: