Provider Demographics
NPI:1710034095
Name:BATES, JERRY ALAN (MD)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:ALAN
Last Name:BATES
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:714 CALM CREST DR
Mailing Address - Street 2:
Mailing Address - City:ROCKWALL
Mailing Address - State:TX
Mailing Address - Zip Code:75087-6454
Mailing Address - Country:US
Mailing Address - Phone:972-974-2952
Mailing Address - Fax:
Practice Address - Street 1:714 CALM CREST DR
Practice Address - Street 2:
Practice Address - City:ROCKWALL
Practice Address - State:TX
Practice Address - Zip Code:75087-6454
Practice Address - Country:US
Practice Address - Phone:972-974-2952
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-05
Last Update Date:2016-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01063076A207R00000X, 390200000X, 2084N0400X
LA3008572084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN01063076AOtherPHYSICIAN LICENSE
LA300857OtherLOUISIANA PHYSICIAN LICENSE