Healthcare Provider Details

I. General information

NPI: 1366901324
Provider Name (Legal Business Name): JEFFREY THOMAS GARDNER II
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/18/2019
Last Update Date: 10/14/2024
Certification Date: 10/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2383 PATE ST N
SNELLVILLE GA
30078-3250
US

IV. Provider business mailing address

2383 PATE ST N
SNELLVILLE GA
30078-3250
US

V. Phone/Fax

Practice location:
  • Phone: 770-972-4845
  • Fax: 770-972-0358
Mailing address:
  • Phone: 770-972-4845
  • Fax: 770-972-0358

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number4306
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number101335
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: