Provider Demographics
NPI:1720071822
Name:BATES, NELSON RICHARD (OD)
Entity type:Individual
Prefix:DR
First Name:NELSON
Middle Name:RICHARD
Last Name:BATES
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2625 W ALAMEDA AVE
Mailing Address - Street 2:208
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91505-4806
Mailing Address - Country:US
Mailing Address - Phone:818-845-3557
Mailing Address - Fax:818-845-2600
Practice Address - Street 1:2625 W ALAMEDA AVE
Practice Address - Street 2:208
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91505-4806
Practice Address - Country:US
Practice Address - Phone:818-845-3557
Practice Address - Fax:818-845-2600
Is Sole Proprietor?:No
Enumeration Date:2005-08-24
Last Update Date:2012-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT5501152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0055010Medicaid
CAU54210Medicare UPIN
CASD0055010Medicaid
CAWOP5501AMedicare ID - Type Unspecified