Healthcare Provider Details

I. General information

NPI: 1497730758
Provider Name (Legal Business Name): GRACE ELLEN GATES MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/09/2005
Last Update Date: 03/31/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1075 CAMINO DEL RIO S
SAN DIEGO CA
92108-3538
US

IV. Provider business mailing address

1075 CAMINO DEL RIO S
SAN DIEGO CA
92108-3538
US

V. Phone/Fax

Practice location:
  • Phone: 619-881-4500
  • Fax: 619-291-0959
Mailing address:
  • Phone: 619-881-4500
  • Fax: 619-291-0959

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number227319
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberC54094
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: