Healthcare Provider Details

I. General information

NPI: 1336131473
Provider Name (Legal Business Name): MARK A GARDNER DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2005
Last Update Date: 11/25/2020
Certification Date: 11/25/2020
Deactivation Date: 03/22/2006
Reactivation Date: 03/27/2006

III. Provider practice location address

510 BUTLER AVE
MARTINSBURG WV
25405-9990
US

IV. Provider business mailing address

510 BUTLER AVE
MARTINSBURG WV
25405-9990
US

V. Phone/Fax

Practice location:
  • Phone: 304-263-0811
  • Fax: 800-817-3807
Mailing address:
  • Phone: 304-263-0811
  • Fax: 800-817-3807

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0000X
TaxonomySports Medicine Podiatrist
License Number0103000917
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: