Provider Demographics
NPI:1447767710
Name:GATES, VANESSA LOUISE (MS, DABR, DABSNM)
Entity Type:Individual
Prefix:MS
First Name:VANESSA
Middle Name:LOUISE
Last Name:GATES
Suffix:
Gender:F
Credentials:MS, DABR, DABSNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 E ONTARIO ST APT 1010
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-7167
Mailing Address - Country:US
Mailing Address - Phone:312-520-2893
Mailing Address - Fax:
Practice Address - Street 1:251 E HURON ST
Practice Address - Street 2:GALTER PAVILION 8-118
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611
Practice Address - Country:US
Practice Address - Phone:312-926-3138
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-08
Last Update Date:2018-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILIL-01037-022085R0205X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0205XAllopathic & Osteopathic PhysiciansRadiologyRadiological Physics
Provider Identifiers
StateIdentifier IDID TypeIssuer
P2367OtherAMERICAN BOARD OF RADIOLOGY - MEDICAL PHYSICS CERTIFICATE