Provider Demographics
NPI:1144210451
Name:BATES, JACKSON (MD)
Entity Type:Individual
Prefix:DR
First Name:JACKSON
Middle Name:
Last Name:BATES
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 1:54 TOWER RD NE
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060-6977
Mailing Address - Country:US
Mailing Address - Phone:770-427-4682
Mailing Address - Fax:770-499-8562
Practice Address - Street 1:54 TOWER RD NE
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-6977
Practice Address - Country:US
Practice Address - Phone:770-427-4682
Practice Address - Fax:770-499-8562
Is Sole Proprietor?:No
Enumeration Date:2005-10-27
Last Update Date:2011-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA016554207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine