Healthcare Provider Details

I. General information

NPI: 1720125313
Provider Name (Legal Business Name): CAROL J. GARDNER, DO PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/31/2007
Last Update Date: 11/16/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

905 ROOSEVELT HWY SUITE 210
COLCHESTER VT
05446-4475
US

IV. Provider business mailing address

905 ROOSEVELT HWY SUITE 210
COLCHESTER VT
05446-4475
US

V. Phone/Fax

Practice location:
  • Phone: 802-879-6544
  • Fax: 802-879-0022
Mailing address:
  • Phone: 802-879-6544
  • Fax: 802-879-0022

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number032-000053
License Number StateVT

VIII. Authorized Official

Name: CAROL J. GARDNER
Title or Position: PHYSICIAN
Credential: D.O.
Phone: 802-879-6544