Provider Demographics
NPI:1629136767
Name:GATES, JEREMY D (MD)
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:D
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 1:4003 RAWLINS ST
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82001-1800
Mailing Address - Country:US
Mailing Address - Phone:307-323-2679
Mailing Address - Fax:307-323-2740
Practice Address - Street 1:4003 RAWLINS ST
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-1800
Practice Address - Country:US
Practice Address - Phone:307-323-2679
Practice Address - Fax:307-323-2740
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2024-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE23932208600000X
WY10144A208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery