Provider Demographics
NPI:1124405196
Name:GAINES, IRENE
Entity Type:Individual
Prefix:
First Name:IRENE
Middle Name:
Last Name:GAINES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1250 E MARSHALL ST
Mailing Address - Street 2:BOX 980509
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23298-5051
Mailing Address - Country:US
Mailing Address - Phone:804-828-8786
Mailing Address - Fax:804-828-5466
Practice Address - Street 1:4755 OGLETOWN STANTON RD STE 5A43
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19718
Practice Address - Country:US
Practice Address - Phone:302-623-0188
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-29
Last Update Date:2018-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC1-0012842207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine