Provider Demographics
NPI:1801826763
Name:GAINES, JUANITA R (MD)
Entity Type:Individual
Prefix:
First Name:JUANITA
Middle Name:R
Last Name:GAINES
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6045 BRIDGETOWN RD
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45248-3049
Mailing Address - Country:US
Mailing Address - Phone:513-981-4105
Mailing Address - Fax:513-347-4620
Practice Address - Street 1:6045 BRIDGETOWN RD
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45248-3049
Practice Address - Country:US
Practice Address - Phone:513-981-4105
Practice Address - Fax:513-347-4620
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-04
Last Update Date:2021-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-047464207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0495272Medicaid
OHP00919613OtherMEDICARE RR
A80306Medicare UPIN
OH4195916Medicare PIN