Provider Demographics
NPI:1730275876
Name:GARDNER, JAMES WILLIAM (MD)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:WILLIAM
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 1:3340 E GOLDSTONE WAY
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642
Mailing Address - Country:US
Mailing Address - Phone:208-302-7100
Mailing Address - Fax:208-302-7155
Practice Address - Street 1:315 E ELM ST
Practice Address - Street 2:STE 100
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83605
Practice Address - Country:US
Practice Address - Phone:208-302-7100
Practice Address - Fax:208-302-7155
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2024-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD216301207Q00000X
IDM6671207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID003703700Medicaid
ID1132570Medicaid
ID11325782Medicare PIN
IDF68323Medicare UPIN
ID1132570Medicaid