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General NPI Number Information
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NPI Number | 1366470544
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Entity Type | Individual
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Provider Name | MARK A GARDON MD
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Gender | Male
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Dates
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Enumeration Date | 06/28/2006
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Last Update Date | 05/10/2021
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Provider Practice Location Address
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Address Line | 2845 GREENBRIER RD STE 330
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City | GREEN BAY
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State | WI
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Zip | 54311-6519
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Country | US
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Telephone | 920-288-8350
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Fax | 920-288-8355
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Provider Business Mailing Address
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Address Line | 2845 GREENBRIER RD STE 330 PO BOX 8900
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City | GREEN BAY
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State | WI
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Zip | 54308-8900
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Country | US
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Telephone | 920-288-8350
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Fax | 920-288-8355
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207T00000X
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Taxonomy Name | Neurological Surgery Physician
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License Number | 32288
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License Number State | WI
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