Individual
DR. BRADLEY P GARDNER
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
2025 E 17TH ST, IDAHO FALLS, ID 83404
(208) 524-2025
(208) 529-1924
Mailing address
2025 E 17TH ST, IDAHO FALLS, ID 83404
(208) 524-2025
(208) 529-1924
Taxonomy
Speciality
Code
Description
License number
State
207W00000X
Ophthalmology Physician
Primary
M6282
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000010000074
BLUE SHIELD
ID
01
—
000010000077
BLUE SHIELD
ID
01
—
000010000078
BLUE SHIELD
ID
01
—
312742
BLUE CROSS
WY
01
—
5925A
STATE LIC #
WY
01
—
DD552
BLUE CROSS
ID
01
—
DW227
BLUE CROSS
ID
01
—
J4241
BLUE CROSS
ID
01
—
J6428
BLUE CROSS
ID
Enumeration date
11/28/2006
Last updated
07/08/2007
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