Provider Demographics
NPI:1407874183
Name:GAINES, CARRIE S (OD)
Entity Type:Individual
Prefix:DR
First Name:CARRIE
Middle Name:S
Last Name:GAINES
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:660 S EUCLID AVE
Mailing Address - Street 2:C B 8096
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110-1010
Mailing Address - Country:US
Mailing Address - Phone:314-842-5070
Mailing Address - Fax:314-842-2316
Practice Address - Street 1:11188 TESSON FERRY RD
Practice Address - Street 2:STE 100
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63123-6962
Practice Address - Country:US
Practice Address - Phone:314-842-5070
Practice Address - Fax:314-842-2316
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2009-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOT02777152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO312922412Medicaid
IL$$$$$$$$$Medicaid
033010103Medicare PIN
T91891Medicare UPIN