Provider Demographics
NPI:1740217793
Name:GAINES, KEVIN DON (MD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:DON
Last Name:GAINES
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:PO BOX 1337
Mailing Address - Street 2:
Mailing Address - City:GALLUP
Mailing Address - State:NM
Mailing Address - Zip Code:87305-1337
Mailing Address - Country:US
Mailing Address - Phone:505-722-1000
Mailing Address - Fax:505-726-8740
Practice Address - Street 1:516 E. NIZHONI BLVD
Practice Address - Street 2:
Practice Address - City:GALLUP
Practice Address - State:NM
Practice Address - Zip Code:87301-1337
Practice Address - Country:US
Practice Address - Phone:505-722-1000
Practice Address - Fax:505-726-8740
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2008-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK21745207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM09101071Medicaid
AZ758196Medicaid
TX8HBG15Medicare ID - Type UnspecifiedHSZ005
AZ758196Medicaid
TX8HBG13Medicare ID - Type UnspecifiedHSZ003
H24200Medicare UPIN
TX8HBG11Medicare ID - Type UnspecifiedHSZ001
TX8HBG16Medicare ID - Type UnspecifiedHSZ006
NM09101071Medicaid