Provider Demographics
NPI:1376707901
Name:BATES, DARRYL A (MD)
Entity Type:Individual
Prefix:
First Name:DARRYL
Middle Name:A
Last Name:BATES
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:8575 GIBBS DR STE 202
Mailing Address - Street 2:UCSD MEDICAL GROUP, MAIL CODE 8201
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-1773
Mailing Address - Country:US
Mailing Address - Phone:619-543-1899
Mailing Address - Fax:619-543-3183
Practice Address - Street 1:9333 GENESEE AVE STE 200
Practice Address - Street 2:LA JOLLA FAMILY AND SPORTS MEDICINE
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92121-2113
Practice Address - Country:US
Practice Address - Phone:858-657-8525
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-14
Last Update Date:2023-02-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MEEC081067207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME433017499Medicaid