Provider Demographics
NPI:1972554996
Name:BATES, DOUGLAS J (MD)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:J
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 1:10790 RANCHO BERNARDO RD
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92127-5705
Mailing Address - Country:US
Mailing Address - Phone:858-554-2626
Mailing Address - Fax:
Practice Address - Street 1:10150 SORRENTO VALLEY RD
Practice Address - Street 2:SUITE 320
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92121-1635
Practice Address - Country:US
Practice Address - Phone:858-454-4235
Practice Address - Fax:858-454-4644
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2017-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG646442085R0202X, 2085N0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G646440Medicaid
E61480Medicare UPIN
WG64644CMedicare ID - Type Unspecified
WG64644AMedicare ID - Type Unspecified
WG64644QMedicare ID - Type Unspecified
CA00G646440Medicaid