Healthcare Provider Details

I. General information

NPI: 1306819222
Provider Name (Legal Business Name): MARC GAINES MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/10/2006
Last Update Date: 12/02/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1860 COLONIAL MEDICAL CT
VIRGINIA BEACH VA
23454-3035
US

IV. Provider business mailing address

PO BOX 7068
PORTSMOUTH VA
23707-0068
US

V. Phone/Fax

Practice location:
  • Phone: 757-481-1113
  • Fax: 757-496-3822
Mailing address:
  • Phone: 757-686-3542
  • Fax: 757-686-0230

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number0101027364
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: