Provider Demographics
NPI:1336168947
Name:GAINES, LARA LONGO (MD)
Entity Type:Individual
Prefix:DR
First Name:LARA
Middle Name:LONGO
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 1:6047 RIVERVIEW WAY
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77057
Mailing Address - Country:US
Mailing Address - Phone:713-932-6488
Mailing Address - Fax:713-513-5276
Practice Address - Street 1:8800 KATY FREEWAY
Practice Address - Street 2:SUITE 103
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77024
Practice Address - Country:US
Practice Address - Phone:713-932-6488
Practice Address - Fax:713-513-5276
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2020-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK1241207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXK1241OtherTEXAS MEDICAL LICENSE