Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 213ES0103X | Foot & Ankle Surgery | 016.005608 | IL |
N | 213ES0103X | Foot & Ankle Surgery | 2010021578 | MO |
NPI | 1043521719 |
---|---|
Provider Name | Dr. Gabriel Cardenas JR. |
First Address | House Springs, MO 63051-4320 |
Second Address | Maryville, IL 62062-8587 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 28/06/2010 |
Last Update Date | 17/11/2016 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
F100153987 | (02) | IL |
F100153987 | MEDICARE GROUP PTAN (01) | IL |