Provider Demographics
NPI:1679663124
Name:BATES, MARK J (PHD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:J
Last Name:BATES
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1050 W. PERIMETER RD
Mailing Address - Street 2:MALCOLM GROW MEDICAL CENTER
Mailing Address - City:ANDREWS AFB
Mailing Address - State:MD
Mailing Address - Zip Code:20762
Mailing Address - Country:US
Mailing Address - Phone:240-867-9940
Mailing Address - Fax:
Practice Address - Street 1:1050 W. PERIMETER RD
Practice Address - Street 2:MALCOLM GROW MEDICAL CENTER
Practice Address - City:ANDREWS AFB
Practice Address - State:MD
Practice Address - Zip Code:20762
Practice Address - Country:US
Practice Address - Phone:240-867-9940
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1296103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical