Provider Demographics
NPI:1124040464
Name:GATES, L T (MD)
Entity Type:Individual
Prefix:
First Name:L
Middle Name:T
Last Name:GATES
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 1:6626 E 75TH ST
Mailing Address - Street 2:SUITE 500
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-2805
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2920 N ARLINGTON AVE
Practice Address - Street 2:SUITE B
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46218-3362
Practice Address - Country:US
Practice Address - Phone:317-355-9431
Practice Address - Fax:317-355-9445
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2017-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01037135A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000313170OtherANTHEM
INP00235875OtherRR MEDICARE
IN100068290Medicaid
IN000000313170OtherANTHEM
INB90210Medicare UPIN
IN215210BMedicare PIN