Provider Demographics
NPI:1922168830
Name:HAMMOND, GAINES WARDLAW JR (MD)
Entity Type:Individual
Prefix:DR
First Name:GAINES
Middle Name:WARDLAW
Last Name:HAMMOND
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:GAINES
Other - Middle Name:WARDLAW
Other - Last Name:HAMMOND
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:320 RACETRACK RD NW STE 100C
Mailing Address - Street 2:
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32547-1796
Mailing Address - Country:US
Mailing Address - Phone:850-863-0883
Mailing Address - Fax:850-862-0188
Practice Address - Street 1:320 RACETRACK RD NW STE 100C
Practice Address - Street 2:
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32547-1796
Practice Address - Country:US
Practice Address - Phone:850-863-0883
Practice Address - Fax:850-862-0188
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2023-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP1320208800000X
SC9896208800000X
FLME130427208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL019470200Medicaid
SC098968Medicaid