Healthcare Provider Details

I. General information

NPI: 1518387422
Provider Name (Legal Business Name): BRIAN D. BATES MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2014
Last Update Date: 12/07/2022
Certification Date: 12/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

61 PINE ST
BRISTOL VT
05443-1043
US

IV. Provider business mailing address

720 HARRISON AVE # DOB503
BOSTON MA
02118-2371
US

V. Phone/Fax

Practice location:
  • Phone: 802-453-5028
  • Fax: 802-453-6105
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number42.0013987
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: