Provider Demographics
NPI:1801866355
Name:GAINES, TARA GOODLETT (MD)
Entity type:Individual
Prefix:DR
First Name:TARA
Middle Name:GOODLETT
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:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:311 CODDLE MARKET DR NW
Practice Address - Street 2:STE 100
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28027
Practice Address - Country:US
Practice Address - Phone:980-302-9100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-26
Last Update Date:2023-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200200525208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8913114Medicaid
NC13114OtherBCBS
NC1200893OtherUNITED HEALTHCARE
NC2943796OtherAETNA
NC800286OtherPARTNERS MCR CHOICE
NC280247OtherMAMSI
NCB6712OtherMEDCOST
NC2943796OtherAETNA
NC8913114Medicaid