Provider Demographics
NPI:1063464626
Name:CHRISTENSEN, ROSS A (MD)
Entity Type:Individual
Prefix:
First Name:ROSS
Middle Name:A
Last Name:CHRISTENSEN
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 1:10790 RANCHO BERNARDO RD
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92127-5705
Mailing Address - Country:US
Mailing Address - Phone:858-554-2626
Mailing Address - Fax:
Practice Address - Street 1:9898 GENESEE AVE
Practice Address - Street 2:
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-1205
Practice Address - Country:US
Practice Address - Phone:858-824-4108
Practice Address - Fax:858-824-1310
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2018-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG523522085R0204X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G523520Medicaid
CA00G523520Medicaid
1063464626OtherNPI
CA00G523520OtherBLUE SHIELD PIN
CAWG52352JMedicare PIN
CAWG52352MMedicare PIN
CAWG52352IMedicare PIN
CAP00062590Medicare PIN
CAWG52352KMedicare PIN