Healthcare Provider Details

I. General information

NPI: 1265442727
Provider Name (Legal Business Name): RICHARD G. GWINN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/08/2006
Last Update Date: 02/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 FIR ST
SAN DIEGO CA
92101-2327
US

IV. Provider business mailing address

13537 US HIGHWAY 1 132
SEBASTIAN FL
32958-3760
US

V. Phone/Fax

Practice location:
  • Phone: 858-499-2777
  • Fax:
Mailing address:
  • Phone: 772-918-0104
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberG24818
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberG24818
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberME122910
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberME122910
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: