Provider Demographics
NPI:1942268156
Name:GAINES, EDDIE LEON (MD)
Entity Type:Individual
Prefix:
First Name:EDDIE
Middle Name:LEON
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 1:3800 E LOHMAN AVE
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88011-8273
Mailing Address - Country:US
Mailing Address - Phone:575-522-6500
Mailing Address - Fax:575-522-0591
Practice Address - Street 1:42145 N FAIRGREEN CT
Practice Address - Street 2:
Practice Address - City:ANTHEM
Practice Address - State:AZ
Practice Address - Zip Code:85086-1066
Practice Address - Country:US
Practice Address - Phone:575-405-7697
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2019-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM94250208D00000X, 207KA0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergy
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM26189Medicaid
NMA2610Medicare UPIN
NM341402105Medicare ID - Type Unspecified