Healthcare Provider Details

I. General information

NPI: 1194717801
Provider Name (Legal Business Name): ROBERT ANTHONY GARDNER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2005
Last Update Date: 04/09/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2410 19TH ST SE
RIO RANCHO NM
87124-4857
US

IV. Provider business mailing address

REGIONAL ADMIN OFFICE 3411 N 5TH AVE., STE. 209
PHOENIX AZ
85013-3812
US

V. Phone/Fax

Practice location:
  • Phone: 505-452-4200
  • Fax: 505-452-4201
Mailing address:
  • Phone: 602-789-0344
  • Fax: 602-789-8389

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD2005-0514
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: