Provider Demographics
NPI:1366901324
Name:GARDNER, JEFFREY THOMAS II
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:THOMAS
Last Name:GARDNER
Suffix:II
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2383 PATE ST N
Mailing Address - Street 2:
Mailing Address - City:SNELLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30078-3250
Mailing Address - Country:US
Mailing Address - Phone:770-972-4845
Mailing Address - Fax:770-972-0358
Practice Address - Street 1:2383 PATE ST N
Practice Address - Street 2:
Practice Address - City:SNELLVILLE
Practice Address - State:GA
Practice Address - Zip Code:30078-3250
Practice Address - Country:US
Practice Address - Phone:770-972-4845
Practice Address - Fax:770-972-0358
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-18
Last Update Date:2024-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA4306207N00000X
390200000X
GA101335207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program