Provider Demographics
NPI:1992702260
Name:GATES, TODD JACOB (DO)
Entity type:Individual
Prefix:DR
First Name:TODD
Middle Name:JACOB
Last Name:GATES
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 SHERIDAN RD
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32901-3184
Mailing Address - Country:US
Mailing Address - Phone:321-722-5200
Mailing Address - Fax:321-953-7510
Practice Address - Street 1:2020 COMMERCE DR
Practice Address - Street 2:
Practice Address - City:WEST MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32904-2335
Practice Address - Country:US
Practice Address - Phone:321-952-6000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-01
Last Update Date:2021-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34-0040912084P0800X
FLOS107542084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL003039300Medicaid
GA0667115Medicare ID - Type Unspecified