MEDICARE: GREGORY GERALD GARDNER D.O.

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	207Q00000X	Family Medicine Physician	J4814	TX

General Provider Information

NPI Number	:	1528080744
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GREGORY GERALD GARDNER D.O.

Provider Business Mailing Address
First Line	:	3304 SE LOOP 820 STE B
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76140-1113
Country	:	US
Telephone Number	:	214-616-4892
Fax Number	:	817-984-1857

Provider Business Practice Location Address
First Line	:	3304 SE LOOP 820 STE B
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76140-1113
Country	:	US
Telephone Number	:	214-616-4892
Fax Number	:	817-984-1857

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

Provider Enumeration Date	:	07/24/2006
Last Update Date	:	01/29/2020

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