Provider Demographics
NPI:1356785455
Name:GARDNER, BRIAN (MD)
Entity type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:
Last Name:GARDNER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1215 LEE ST
Mailing Address - Street 2:BOX 800719
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22908-0816
Mailing Address - Country:US
Mailing Address - Phone:434-924-2150
Mailing Address - Fax:434-982-1530
Practice Address - Street 1:1215 LEE ST
Practice Address - Street 2:BOX 800719
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22908-0816
Practice Address - Country:US
Practice Address - Phone:434-924-2150
Practice Address - Fax:434-982-1530
Is Sole Proprietor?:No
Enumeration Date:2013-04-19
Last Update Date:2019-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
SC820702085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC820703Medicaid
SCSCF2284467OtherSC MEDICARE