MEDICARE: DR. LISA L GARDNER DO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207V00000X	Obstetrics & Gynecology Physician	L9698	TX

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	P00364785	OTHER		RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1477578292
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LISA L GARDNER DO

Provider Business Mailing Address
First Line	:	7250 HAWKINS VIEW DR
Second Line	:	STE 411
City	:	FORT WORTH
State	:	TX
Zip	:	76132-3920
Country	:	US
Telephone Number	:	817-644-1758
Fax Number	:	817-644-3112

Provider Business Practice Location Address
First Line	:	7250 HAWKINS VIEW DR
Second Line	:	STE 411
City	:	FORT WORTH
State	:	TX
Zip	:	76132-3920
Country	:	US
Telephone Number	:	817-644-1758
Fax Number	:	817-644-3112

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/13/2006
Last Update Date	:	10/24/2012

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