Basic Information
| Provider Information | |||||||||
| NPI: | 1629050281 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GARDNER | ||||||||
| FirstName: | TINA | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 461 CHERRY BROOK RD | ||||||||
| Address2: | |||||||||
| City: | CANTON | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060194517 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8455278854 | ||||||||
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| Practice Location | |||||||||
| Address1: | 34 MAPLE ST | ||||||||
| Address2: | |||||||||
| City: | NORWALK | ||||||||
| State: | CT | ||||||||
| PostalCode: | 068503894 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2038522000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/18/2005 | ||||||||
| LastUpdateDate: | 10/21/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/21/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 185132 | NY | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 57109 | CT | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.