Basic Information
| Provider Information | |||||||||
| NPI: | 1326433657 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BATES | ||||||||
| FirstName: | KRYSTLE | ||||||||
| MiddleName: | GONDA DAVID | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DAVID | ||||||||
| OtherFirstName: | KRYSTLE | ||||||||
| OtherMiddleName: | GONDA | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 848476 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752848476 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2542024655 | ||||||||
| FaxNumber: | 2542024697 | ||||||||
| Practice Location | |||||||||
| Address1: | 851 N LOOP 340 | ||||||||
| Address2: | |||||||||
| City: | WACO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 76705 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2542027500 | ||||||||
| FaxNumber: | 2542027599 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/02/2015 | ||||||||
| LastUpdateDate: | 09/01/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/01/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | R8314 | TX | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.