Provider Demographics
NPI:1336123504
Name:TATE, DAVID JOHN (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:JOHN
Last Name:TATE
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 1:965 STONECASTLE LN
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95405-5512
Mailing Address - Country:US
Mailing Address - Phone:707-498-9095
Mailing Address - Fax:
Practice Address - Street 1:10 WOODLAND RD
Practice Address - Street 2:
Practice Address - City:SAINT HELENA
Practice Address - State:CA
Practice Address - Zip Code:94574-9554
Practice Address - Country:US
Practice Address - Phone:707-967-5721
Practice Address - Fax:707-967-5722
Is Sole Proprietor?:No
Enumeration Date:2005-12-01
Last Update Date:2017-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG753552085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G753550Medicaid
CA00G753550Medicaid
00G753550Medicare ID - Type Unspecified