Healthcare Provider Details

I. General information

NPI: 1740335686
Provider Name (Legal Business Name): KATHRYN MENTA GARDNER M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/23/2007
Last Update Date: 12/27/2019
Certification Date: 12/27/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

242 26TH ST
SANTA MONICA CA
90402-2552
US

IV. Provider business mailing address

242 26TH ST
SANTA MONICA CA
90402-2552
US

V. Phone/Fax

Practice location:
  • Phone: 310-451-3911
  • Fax: 310-458-4402
Mailing address:
  • Phone: 310-451-3911
  • Fax: 310-458-4402

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License NumberG43380
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207WX0120X
TaxonomyCornea and External Diseases Specialist Physician
License NumberG43380
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: