Provider Demographics
NPI:1730108655
Name:BATES, DOUGLAS L (PT)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:L
Last Name:BATES
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 8419
Mailing Address - Street 2:
Mailing Address - City:BILOXI
Mailing Address - State:MS
Mailing Address - Zip Code:39535-8087
Mailing Address - Country:US
Mailing Address - Phone:228-388-5714
Mailing Address - Fax:228-388-0017
Practice Address - Street 1:2210B MILL STREET EXT
Practice Address - Street 2:
Practice Address - City:LUCEDALE
Practice Address - State:MS
Practice Address - Zip Code:39452-6064
Practice Address - Country:US
Practice Address - Phone:601-947-9005
Practice Address - Fax:601-947-9007
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2009-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT0939225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09015077Medicaid
MS1033218524OtherGROUP NPI
MS09015077Medicaid