Healthcare Provider Details

I. General information

NPI: 1740382480
Provider Name (Legal Business Name): MARION LEE GARDNER JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/02/2006
Last Update Date: 12/03/2025
Certification Date: 12/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10245 NW GLENCOE RD
NORTH PLAINS OR
97133-8233
US

IV. Provider business mailing address

10245 NW GLENCOE RD
NORTH PLAINS OR
97133-8233
US

V. Phone/Fax

Practice location:
  • Phone: 503-647-9261
  • Fax: 503-647-1230
Mailing address:
  • Phone: 503-647-9261
  • Fax: 503-647-1230

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD17617
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: