Provider Demographics
NPI:1508080029
Name:BATES, SUSAN ELAINE (MD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:ELAINE
Last Name:BATES
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 1:630 W 168TH ST
Mailing Address - Street 2:BOX 4
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10032-3725
Mailing Address - Country:US
Mailing Address - Phone:212-342-5155
Mailing Address - Fax:
Practice Address - Street 1:161 FORT WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032-3729
Practice Address - Country:US
Practice Address - Phone:212-342-5155
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-13
Last Update Date:2023-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0031972207RX0202X
NY281291207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDPHS000Medicare UPIN