Healthcare Provider Details

I. General information

NPI: 1023179850
Provider Name (Legal Business Name): ROBERT S. GARDNER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: R S ISAAC GARDNER M.D.

II. Dates (important events)

Enumeration Date: 12/13/2006
Last Update Date: 09/28/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 COLLEGE AVE 211
SANTA ROSA CA
95404-4118
US

IV. Provider business mailing address

525 COLLEGE AVE 211
SANTA ROSA CA
95404-4118
US

V. Phone/Fax

Practice location:
  • Phone: 707-575-7647
  • Fax: 707-575-7739
Mailing address:
  • Phone: 707-575-7647
  • Fax: 707-575-7739

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License NumberG17718
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberG17718
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: