Provider Demographics
NPI:1982849543
Name:GAINES, CAROL (MD)
Entity Type:Individual
Prefix:DR
First Name:CAROL
Middle Name:
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 1:312 EAST WISCONSIN AVENUE
Mailing Address - Street 2:SUITE 208
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53202
Mailing Address - Country:US
Mailing Address - Phone:414-731-0019
Mailing Address - Fax:414-271-6433
Practice Address - Street 1:2448 S 102ND ST
Practice Address - Street 2:SUITE 270
Practice Address - City:WEST ALLIS
Practice Address - State:WI
Practice Address - Zip Code:53227-2466
Practice Address - Country:US
Practice Address - Phone:414-543-9600
Practice Address - Fax:414-543-9601
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-11
Last Update Date:2008-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI25320-020172V00000X
IL036.119429172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker