Basic Information
| Provider Information | |||||||||
| NPI: | 1689093288 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GARDNER | ||||||||
| FirstName: | ADAM | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 13401 N WESTERN AVE STE 200 | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731141410 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052523450 | ||||||||
| FaxNumber: | 4052523499 | ||||||||
| Practice Location | |||||||||
| Address1: | 13401 N WESTERN AVE STE 200 | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731141410 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052523450 | ||||||||
| FaxNumber: | 4052523499 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/10/2014 | ||||||||
| LastUpdateDate: | 12/30/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/30/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 30575 | OK | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.