Provider Demographics
NPI:1912915380
Name:GAINES, PETER MARSHALL (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:MARSHALL
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 1:830 SCENIC DR
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-6131
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:401 PARADISE RD
Practice Address - Street 2:SUITE E
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95351-3104
Practice Address - Country:US
Practice Address - Phone:209-558-4000
Practice Address - Fax:209-558-5036
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-03
Last Update Date:2023-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG64747207QG0300X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
00G647470Medicare ID - Type UnspecifiedMCR INDIVIDUAL
E54838Medicare UPIN