=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770010118
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RUBY GARDNER DPM
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/16/2017
-----------------------------------------------------
Last Update Date | 01/04/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 24 N CLOVER DR
-----------------------------------------------------
City | GREAT NECK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11021-1038
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-801-7893
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 24 N CLOVER DR
-----------------------------------------------------
City | GREAT NECK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11021-1038
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-801-7893
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 133N00000X
-----------------------------------------------------
Taxonomy Name | Nutritionist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 213E00000X
-----------------------------------------------------
Taxonomy Name | Podiatrist
-----------------------------------------------------
License Number | N007041
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 213EP0504X
-----------------------------------------------------
Taxonomy Name | Public Medicine Podiatrist
-----------------------------------------------------
License Number | N007041
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 213EP1101X
-----------------------------------------------------
Taxonomy Name | Primary Podiatric Medicine Podiatrist
-----------------------------------------------------
License Number | N007041
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 213ER0200X
-----------------------------------------------------
Taxonomy Name | Radiology Podiatrist
-----------------------------------------------------
License Number | N007041
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #6
-----------------------------------------------------
Taxonomy Code | 213ES0000X
-----------------------------------------------------
Taxonomy Name | Sports Medicine Podiatrist
-----------------------------------------------------
License Number | N007041
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #7
-----------------------------------------------------
Taxonomy Code | 213ES0131X
-----------------------------------------------------
Taxonomy Name | Foot Surgery Podiatrist
-----------------------------------------------------
License Number | N007041
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #8
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #9
-----------------------------------------------------
Taxonomy Code | 213ES0103X
-----------------------------------------------------
Taxonomy Name | Foot & Ankle Surgery Podiatrist
-----------------------------------------------------
License Number | N007041
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------