Provider Demographics
NPI:1003179425
Name:GATES, MARCUS J (MD)
Entity Type:Individual
Prefix:
First Name:MARCUS
Middle Name:J
Last Name:GATES
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1700 HOSPITAL SOUTH DR STE 102
Mailing Address - Street 2:
Mailing Address - City:AUSTELL
Mailing Address - State:GA
Mailing Address - Zip Code:30106-8116
Mailing Address - Country:US
Mailing Address - Phone:470-956-4410
Mailing Address - Fax:707-450-7827
Practice Address - Street 1:1700 HOSPITAL SOUTH DR STE 102
Practice Address - Street 2:
Practice Address - City:AUSTELL
Practice Address - State:GA
Practice Address - Zip Code:30106-8116
Practice Address - Country:US
Practice Address - Phone:470-956-4410
Practice Address - Fax:770-745-0782
Is Sole Proprietor?:No
Enumeration Date:2012-06-20
Last Update Date:2020-03-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN56552207T00000X
GA82595207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAENROLLEDMedicaid
MNENROLLEDMedicaid
MNENROLLEDMedicaid