Healthcare Provider Details

I. General information

NPI: 1922050483
Provider Name (Legal Business Name): ANGELA E GARDNER O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2006
Last Update Date: 09/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1224 STATE ROUTE 29
GREENWICH NY
12834-6120
US

IV. Provider business mailing address

1224 STATE ROUTE 29
GREENWICH NY
12834-6120
US

V. Phone/Fax

Practice location:
  • Phone: 518-692-2040
  • Fax: 518-692-2440
Mailing address:
  • Phone: 518-692-2040
  • Fax: 518-692-2440

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number005918
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: