Provider Demographics
NPI:1003853045
Name:YATES, TRAVIS (DO)
Entity Type:Individual
Prefix:
First Name:TRAVIS
Middle Name:
Last Name:YATES
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 QUIET VALLEY CV
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:MS
Mailing Address - Zip Code:38655-8430
Mailing Address - Country:US
Mailing Address - Phone:662-234-1881
Mailing Address - Fax:
Practice Address - Street 1:REBEL DRIVE
Practice Address - Street 2:STUDENT HEALTH CENTER
Practice Address - City:UNIVERSITY
Practice Address - State:MS
Practice Address - Zip Code:38677
Practice Address - Country:US
Practice Address - Phone:662-915-7274
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-31
Last Update Date:2008-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS9830207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
B66210Medicare UPIN