Provider Demographics
NPI:1497730758
Name:GATES, GRACE ELLEN (MD)
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:ELLEN
Last Name:GATES
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1075 CAMINO DEL RIO S
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92108-3538
Mailing Address - Country:US
Mailing Address - Phone:619-881-4500
Mailing Address - Fax:619-291-0959
Practice Address - Street 1:1075 CAMINO DEL RIO S
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-3538
Practice Address - Country:US
Practice Address - Phone:619-881-4500
Practice Address - Fax:619-291-0959
Is Sole Proprietor?:No
Enumeration Date:2005-12-09
Last Update Date:2017-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY227319207V00000X
CAC54094207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY645C0XYPW1Medicare PIN