Basic Information
Provider Information | |||||||||
NPI: | 1992702260 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GATES | ||||||||
FirstName: | TODD | ||||||||
MiddleName: | JACOB | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | D.O. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 400 SHERIDAN RD | ||||||||
Address2: |   | ||||||||
City: | MELBOURNE | ||||||||
State: | FL | ||||||||
PostalCode: | 329013184 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3217225200 | ||||||||
FaxNumber: | 3219537510 | ||||||||
Practice Location | |||||||||
Address1: | 2020 COMMERCE DR | ||||||||
Address2: |   | ||||||||
City: | WEST MELBOURNE | ||||||||
State: | FL | ||||||||
PostalCode: | 329042335 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3219526000 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/01/2005 | ||||||||
LastUpdateDate: | 07/16/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/16/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 34-004091 | OH | N |   | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084P0800X | OS10754 | FL | Y |   | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
ID | Type | State | Issuer | Description | 003039300 | 05 | FL |   | MEDICAID |