Healthcare Provider Details

I. General information

NPI: 1548794936
Provider Name (Legal Business Name): STEPHANIE SULLIVAN GARDNER M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/12/2017
Last Update Date: 08/04/2022
Certification Date: 08/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6565 FANNIN ST
HOUSTON TX
77030-2703
US

IV. Provider business mailing address

1411 EAGLE FALLS DR
FRIENDSWOOD TX
77546-7847
US

V. Phone/Fax

Practice location:
  • Phone: 713-790-3311
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XX0004X
TaxonomyOrthopaedic Foot and Ankle Surgery Physician
License Number1548794936
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: