Provider Demographics
NPI:1962418400
Name:GATES, JACKSON L (MD)
Entity type:Individual
Prefix:DR
First Name:JACKSON
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 1:777 CLEVELAND AVE SW
Mailing Address - Street 2:SUITE 100
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30315-7129
Mailing Address - Country:US
Mailing Address - Phone:404-763-0093
Mailing Address - Fax:
Practice Address - Street 1:1880 LANCASTER DRIVE
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30013-6433
Practice Address - Country:US
Practice Address - Phone:678-591-6509
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2010-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA038767208D00000X, 207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
G98376Medicare UPIN