Provider Demographics
NPI:1073549200
Name:ROSS, KELLY G (OD)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:G
Last Name:ROSS
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 349
Mailing Address - Street 2:
Mailing Address - City:WALNUT RIDGE
Mailing Address - State:AR
Mailing Address - Zip Code:72476-0349
Mailing Address - Country:US
Mailing Address - Phone:870-886-2632
Mailing Address - Fax:870-886-1514
Practice Address - Street 1:1014 W MAIN ST
Practice Address - Street 2:
Practice Address - City:WALNUT RIDGE
Practice Address - State:AR
Practice Address - Zip Code:72476-1004
Practice Address - Country:US
Practice Address - Phone:870-886-2632
Practice Address - Fax:870-886-1514
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2008-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2485152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR137089722Medicaid
AR49571Medicare ID - Type UnspecifiedOPTOMETRY
ARU71292Medicare UPIN