1336129725 NPI number — WALTER G GARNER III MD

Table of content: WALTER G GARNER III MD (NPI 1336129725)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336129725 NPI number — WALTER G GARNER III MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GARNER
Provider First Name:
WALTER
Provider Middle Name:
G
Provider Name Prefix Text:
Provider Name Suffix Text:
III
Provider Credential Text:
MD
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:
1336129725
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1665 KINGSLEY AVE
Provider Second Line Business Mailing Address:
SUITE 107
Provider Business Mailing Address City Name:
ORANGE PARK
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32073-4490
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-269-6565
Provider Business Mailing Address Fax Number:
904-264-0529

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1665 KINGSLEY AVE
Provider Second Line Business Practice Location Address:
SUITE 107
Provider Business Practice Location Address City Name:
ORANGE PARK
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32073-4490
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-269-6565
Provider Business Practice Location Address Fax Number:
904-264-0529
Provider Enumeration Date:
01/20/2006

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: 174400000X , with the licence number:  ME90186 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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