Provider Demographics
NPI:1700822491
Name:BATES, RODNEY JR (DO)
Entity Type:Individual
Prefix:
First Name:RODNEY
Middle Name:
Last Name:BATES
Suffix:JR
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36 PROFESSIONAL PLZ
Mailing Address - Street 2:
Mailing Address - City:REXBURG
Mailing Address - State:ID
Mailing Address - Zip Code:83440-2049
Mailing Address - Country:US
Mailing Address - Phone:208-359-9411
Mailing Address - Fax:208-656-8444
Practice Address - Street 1:36 PROFESSIONAL PLZ
Practice Address - Street 2:
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440-2049
Practice Address - Country:US
Practice Address - Phone:208-359-9411
Practice Address - Fax:208-656-8444
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2012-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDO-0359207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807206700Medicaid
ID000010151181OtherREGENCE BLUE SHIELD OF ID
IDS5759OtherBLUE CROSS OF IDAHO
ID807206700Medicaid
ID000010151181OtherREGENCE BLUE SHIELD OF ID