Provider Demographics
NPI:1952406639
Name:GATES, DOUGLAS L (MD)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:L
Last Name:GATES
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 1:305 W JACKSON ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62901-1474
Mailing Address - Country:US
Mailing Address - Phone:618-457-0404
Mailing Address - Fax:618-457-6579
Practice Address - Street 1:305 W JACKSON ST
Practice Address - Street 2:SUITE 100
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901-1474
Practice Address - Country:US
Practice Address - Phone:618-457-0404
Practice Address - Fax:618-457-6579
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2008-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036090833207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL271450OtherHEALTHLINK
IL027521OtherHEALTH ALLIANCE
IL036090833Medicaid
IL3930184OtherBLUE CROSS BLUE SHIELD
IL235776OtherHARMONY HEALTH
IL036090833Medicaid
IL709910Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER
ILG10093Medicare UPIN