Healthcare Provider Details

I. General information

NPI: 1679848766
Provider Name (Legal Business Name): JAMES MICHAEL GARDNER JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: JIM MICHAEL GARDNER JR.

II. Dates (important events)

Enumeration Date: 03/21/2012
Last Update Date: 07/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 UNIVERSITY BLVD STE 208
JUPITER FL
33458-2775
US

IV. Provider business mailing address

500 UNIVERSITY BLVD STE 208
JUPITER FL
33458-2775
US

V. Phone/Fax

Practice location:
  • Phone: 561-627-3130
  • Fax: 561-627-8971
Mailing address:
  • Phone: 561-627-3130
  • Fax: 561-627-8971

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number02004702A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number02004702A
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberOS15445
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: