Provider Demographics
NPI:1720154420
Name:GAYNOR, MARTIN (MD)
Entity Type:Individual
Prefix:DR
First Name:MARTIN
Middle Name:
Last Name:GAYNOR
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 1:139 SANDWICH ST
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02360-2449
Mailing Address - Country:US
Mailing Address - Phone:508-747-5900
Mailing Address - Fax:
Practice Address - Street 1:139 SANDWICH ST
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02360-2449
Practice Address - Country:US
Practice Address - Phone:508-747-5900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-27
Last Update Date:2008-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA30901208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0198927Medicaid
MA0198927Medicaid
MAC04442Medicare PIN