Provider Demographics
NPI:1073824371
Name:GATES, ROBERT EDWARD JR (LAC, AP)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:EDWARD
Last Name:GATES
Suffix:JR
Gender:M
Credentials:LAC, AP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1103 ERMINE AVE
Mailing Address - Street 2:
Mailing Address - City:WINTER SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32708-4131
Mailing Address - Country:US
Mailing Address - Phone:407-852-8584
Mailing Address - Fax:
Practice Address - Street 1:2040 WINTER SPRINGS BLVD
Practice Address - Street 2:
Practice Address - City:OVIEDO
Practice Address - State:FL
Practice Address - Zip Code:32765-9347
Practice Address - Country:US
Practice Address - Phone:407-852-8584
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-01
Last Update Date:2011-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI673-055171100000X
FLAP2809171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist