Provider Demographics
NPI:1265442727
Name:GWINN, RICHARD G (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:G
Last Name:GWINN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13537 US HIGHWAY 1
Mailing Address - Street 2:132
Mailing Address - City:SEBASTIAN
Mailing Address - State:FL
Mailing Address - Zip Code:32958-3760
Mailing Address - Country:US
Mailing Address - Phone:772-918-0104
Mailing Address - Fax:
Practice Address - Street 1:300 FIR ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92101-2327
Practice Address - Country:US
Practice Address - Phone:858-499-2777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2015-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG24818207P00000X, 208D00000X
FLME122910207P00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWG24818AMedicare ID - Type Unspecified
CA00G248180Medicaid
CAA42409Medicare UPIN