Healthcare Provider Details

I. General information

NPI: 1063090561
Provider Name (Legal Business Name): COLE DELWORTH GARDNER DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2021
Last Update Date: 04/18/2024
Certification Date: 04/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10500 MONTGOMERY RD
MONTGOMERY OH
45242-4402
US

IV. Provider business mailing address

1846 N 350 E
CENTERVILLE UT
84014-3117
US

V. Phone/Fax

Practice location:
  • Phone: 513-865-1111
  • Fax:
Mailing address:
  • Phone: 385-335-1183
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number13689443-0501
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: