Healthcare Provider Details

I. General information

NPI: 1942268156
Provider Name (Legal Business Name): EDDIE LEON GAINES M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2006
Last Update Date: 03/27/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

42145 N FAIRGREEN CT
ANTHEM AZ
85086-1066
US

IV. Provider business mailing address

3800 E LOHMAN AVE
LAS CRUCES NM
88011-8273
US

V. Phone/Fax

Practice location:
  • Phone: 575-405-7697
  • Fax:
Mailing address:
  • Phone: 575-522-6500
  • Fax: 575-522-0591

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207KA0200X
TaxonomyAllergy Physician
License Number94250
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number94250
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: