Provider Demographics
NPI:1639103021
Name:MARTIN, GAINES CHARLES (MD)
Entity Type:Individual
Prefix:DR
First Name:GAINES
Middle Name:CHARLES
Last Name:MARTIN
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 1:1409 KINGSLEY AVE, SUITE 9G
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073
Mailing Address - Country:US
Mailing Address - Phone:904-637-0007
Mailing Address - Fax:866-482-9906
Practice Address - Street 1:1409 KINGSLEY AVE, SUITE 9G
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073
Practice Address - Country:US
Practice Address - Phone:904-637-0007
Practice Address - Fax:866-482-9906
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2013-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME81545207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
2687947OtherAETNA HMO
279755OtherAVMED
51002OtherBCBS MEDICARE
FL59-3720215Medicaid
FL266202700Medicaid
FLH43771Medicare UPIN
FL266202700Medicaid
FL51002YMedicare PIN
51002OtherBCBS MEDICARE