Provider Demographics
NPI:1992711006
Name:GATES, MARK L (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
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 1:70 DOCTORS PARK
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63703-4928
Mailing Address - Country:US
Mailing Address - Phone:573-334-6071
Mailing Address - Fax:573-334-4739
Practice Address - Street 1:70 DOCTORS PARK
Practice Address - Street 2:
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63703-4928
Practice Address - Country:US
Practice Address - Phone:573-334-6071
Practice Address - Fax:573-334-4739
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2022-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO1079672085N0904X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085N0904XAllopathic & Osteopathic PhysiciansRadiologyNuclear Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO207979006Medicaid
277561OtherHEALTHLINK
IL036-098177OtherIL BLUE CROSS BLUE SHIELD
430954380CAPOtherMERCY HEALTH PLAN
AR143792001Medicaid
MO185214OtherMO BLUE CROSS BLUE SHIELD
063896OtherHEALTH ALLIANCE
IL036-098177OtherIL BLUE CROSS BLUE SHIELD
IL300113329Medicare ID - Type UnspecifiedIL RAILROAD MEDICARE
MO207979006Medicaid
MO300058004Medicare ID - Type UnspecifiedMO RAILROAD MEDICARE
ILL73241Medicare ID - Type Unspecified