Healthcare Provider Details

I. General information

NPI: 1477759884
Provider Name (Legal Business Name): RICHARD KENNETH GAINES M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/22/2007
Last Update Date: 11/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2699 STIRLING RD SUITE C-201
FORT LAUDERDALE FL
33312
US

IV. Provider business mailing address

3389 SHERIDAN ST #439
HOLLYWOOD FL
33021-3606
US

V. Phone/Fax

Practice location:
  • Phone: 877-939-4246
  • Fax: 877-939-4248
Mailing address:
  • Phone: 954-962-5888
  • Fax: 954-961-2433

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License NumberME46641
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: