Healthcare Provider Details

I. General information

NPI: 1104261031
Provider Name (Legal Business Name): LESLEY GARDINER MD PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/06/2013
Last Update Date: 04/11/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

404 RIVER POINTE DR SUITE 100
CONROE TX
77304-2836
US

IV. Provider business mailing address

PO BOX 841969
DALLAS TX
75284-1969
US

V. Phone/Fax

Practice location:
  • Phone: 936-756-8108
  • Fax: 936-441-4013
Mailing address:
  • Phone: 832-825-8901
  • Fax: 832-825-8901

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberBP10047234
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberQ7875
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: