Basic Information
| Provider Information | |||||||||
| NPI: | 1972554996 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BATES | ||||||||
| FirstName: | DOUGLAS | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10790 RANCHO BERNARDO RD | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921275705 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8585542626 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 10150 SORRENTO VALLEY RD | ||||||||
| Address2: | SUITE 320 | ||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921211635 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8584544235 | ||||||||
| FaxNumber: | 8584544644 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2006 | ||||||||
| LastUpdateDate: | 06/02/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | G64644 | CA | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085N0700X | G64644 | CA | N | Allopathic & Osteopathic Physicians | Radiology | Neuroradiology |
ID Information
| ID | Type | State | Issuer | Description | 00G646440 | 05 | CA | MEDICAID |