Healthcare Provider Details

I. General information

NPI: 1548471832
Provider Name (Legal Business Name): MEGAN E GARDNER MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2007
Last Update Date: 01/31/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2400 HOSPITAL DR. SUITE 120
BOSSIER CITY LA
71111-2386
US

IV. Provider business mailing address

2400 HOSPITAL DR. SUITE 120
BOSSIER CITY LA
71111-2386
US

V. Phone/Fax

Practice location:
  • Phone: 318-742-6710
  • Fax: 318-747-5393
Mailing address:
  • Phone: 318-742-6710
  • Fax: 318-747-5393

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number202868
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: