Provider Demographics
NPI:1053345934
Name:GARDNER, CRAIG JOSEPH (DO)
Entity type:Individual
Prefix:
First Name:CRAIG
Middle Name:JOSEPH
Last Name:GARDNER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 INDUSTRIAL BLVD
Mailing Address - Street 2:SUITE 204
Mailing Address - City:PAOLI
Mailing Address - State:PA
Mailing Address - Zip Code:19301-1632
Mailing Address - Country:US
Mailing Address - Phone:610-644-6251
Mailing Address - Fax:610-644-1440
Practice Address - Street 1:11 INDUSTRIAL BLVD STE 204
Practice Address - Street 2:
Practice Address - City:PAOLI
Practice Address - State:PA
Practice Address - Zip Code:19301-1620
Practice Address - Country:US
Practice Address - Phone:610-644-6251
Practice Address - Fax:610-644-1440
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2021-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS0126302084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
I51412Medicare UPIN
100221Medicare ID - Type Unspecified