Healthcare Provider Details

I. General information

NPI: 1962588111
Provider Name (Legal Business Name): SAMUEL D GARDNER DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/31/2006
Last Update Date: 09/26/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

805 MAIN ST
SALMON ID
83467-0000
US

IV. Provider business mailing address

203 S DAISY ST
SALMON ID
83467-0000
US

V. Phone/Fax

Practice location:
  • Phone: 208-756-6212
  • Fax: 208-756-6336
Mailing address:
  • Phone: 208-756-5600
  • Fax: 208-756-4169

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberO-174
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: