Provider Demographics
NPI:1528626363
Name:GARDNER, REID BRIAN (OD)
Entity type:Individual
Prefix:
First Name:REID
Middle Name:BRIAN
Last Name:GARDNER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:825 5TH AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:CHAMBERSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17201-4214
Mailing Address - Country:US
Mailing Address - Phone:717-262-9700
Mailing Address - Fax:
Practice Address - Street 1:825 5TH AVE STE 102
Practice Address - Street 2:
Practice Address - City:CHAMBERSBURG
Practice Address - State:PA
Practice Address - Zip Code:17201-4214
Practice Address - Country:US
Practice Address - Phone:717-262-9700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-05
Last Update Date:2020-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG003711152W00000X
MDTA2759152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist