Provider Demographics
NPI:1033220611
Name:ROSS, PHILLIP LEON (MD)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:LEON
Last Name:ROSS
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 1:350 30TH ST
Mailing Address - Street 2:STE 100
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94609-3424
Mailing Address - Country:US
Mailing Address - Phone:510-204-8290
Mailing Address - Fax:510-273-8977
Practice Address - Street 1:350 30TH ST
Practice Address - Street 2:STE 100
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94609-3424
Practice Address - Country:US
Practice Address - Phone:510-204-8290
Practice Address - Fax:510-273-8977
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2010-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA91162208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A911620Medicaid
CA00A911620Medicare PIN