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

Table of content: (NPI 1942051636)

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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