Healthcare Provider Details

I. General information

NPI: 1336465566
Provider Name (Legal Business Name): JEFFREY PAUL GARDINER D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2010
Last Update Date: 06/10/2020
Certification Date: 06/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1055 N 300 W SUITE 204
PROVO UT
84604-3344
US

IV. Provider business mailing address

1055 N 300 W SUITE 204
PROVO UT
84604-3344
US

V. Phone/Fax

Practice location:
  • Phone: 801-357-7373
  • Fax: 801-357-7217
Mailing address:
  • Phone: 801-357-7373
  • Fax: 801-357-7217

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number34011221
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: