1043521719 NPI number — DR. GABRIEL CARDENAS JR. D.P.M.

Table of content: DR. GABRIEL CARDENAS JR. D.P.M. (NPI 1043521719)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043521719 NPI number — DR. GABRIEL CARDENAS JR. D.P.M.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CARDENAS
Provider First Name:
GABRIEL
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
JR.
Provider Credential Text:
D.P.M.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1043521719
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/17/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
521 MEADOW GLEN CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HOUSE SPRINGS
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63051-4320
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
618-514-1308
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6810 STATE ROUTE 162
Provider Second Line Business Practice Location Address:
SUITE 20
Provider Business Practice Location Address City Name:
MARYVILLE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62062-8587
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-288-2835
Provider Business Practice Location Address Fax Number:
618-288-6162
Provider Enumeration Date:
06/28/2010

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 213ES0103X , with the licence number:  2010021578 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 213ES0103X , with the licence number: 016.005608 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: F100153987 . This is a "MEDICARE GROUP PTAN" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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