Healthcare Provider Details

I. General information

NPI: 1366470544
Provider Name (Legal Business Name): MARK A GARDON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2006
Last Update Date: 05/10/2021
Certification Date: 05/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2845 GREENBRIER RD STE 330
GREEN BAY WI
54311-6519
US

IV. Provider business mailing address

2845 GREENBRIER RD STE 330 PO BOX 8900
GREEN BAY WI
54308-8900
US

V. Phone/Fax

Practice location:
  • Phone: 920-288-8350
  • Fax: 920-288-8355
Mailing address:
  • Phone: 920-288-8350
  • Fax: 920-288-8355

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number32288
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: