Provider Demographics
NPI:1720170228
Name:BATES, JOHN ROBERT (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:ROBERT
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 1:105 WYOMING ST STE B
Mailing Address - Street 2:
Mailing Address - City:LANDER
Mailing Address - State:WY
Mailing Address - Zip Code:82520-3919
Mailing Address - Country:US
Mailing Address - Phone:307-206-1121
Mailing Address - Fax:
Practice Address - Street 1:105 WYOMING ST STE B
Practice Address - Street 2:
Practice Address - City:LANDER
Practice Address - State:WY
Practice Address - Zip Code:82520-3919
Practice Address - Country:US
Practice Address - Phone:307-206-1121
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-29
Last Update Date:2024-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-130882084P0800X
ORMD248282084P0800X
WY14728A2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR240533Medicaid
WY225939700Medicaid
OR102770Medicare UPIN