Provider Demographics
NPI:1255408217
Name:GARDNER, BRADLEY P (MD)
Entity type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:P
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 1:2025 E 17TH ST
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404
Mailing Address - Country:US
Mailing Address - Phone:208-524-2025
Mailing Address - Fax:208-529-1924
Practice Address - Street 1:2025 E 17TH ST
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404
Practice Address - Country:US
Practice Address - Phone:208-524-2025
Practice Address - Fax:208-529-1924
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM6282207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010000074OtherBLUE SHIELD
ID000010000078OtherBLUE SHIELD
WY312742OtherBLUE CROSS
WY5925AOtherSTATE LIC #
IDDD552OtherBLUE CROSS
IDDW227OtherBLUE CROSS
IDJ4241OtherBLUE CROSS
IDJ6428OtherBLUE CROSS
ID000010000077OtherBLUE SHIELD
ID1129178Medicare ID - Type Unspecified
IDJ6428OtherBLUE CROSS
ID000010000078OtherBLUE SHIELD
IDJ4241OtherBLUE CROSS