Provider Demographics
NPI:1093797623
Name:ROSS, LARA L (MD)
Entity Type:Individual
Prefix:DR
First Name:LARA
Middle Name:L
Last Name:ROSS
Suffix:
Gender:F
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:PO BOX 5166
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39302-5166
Mailing Address - Country:US
Mailing Address - Phone:601-703-4282
Mailing Address - Fax:601-703-4597
Practice Address - Street 1:1500 HWY 19 N
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39307-5335
Practice Address - Country:US
Practice Address - Phone:601-696-3232
Practice Address - Fax:601-696-3231
Is Sole Proprietor?:No
Enumeration Date:2005-11-18
Last Update Date:2013-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS18007208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00113837OtherRAILROAD MEDICARE
731-04011OtherBLUE CROSS OF AL
AL009946185Medicaid
MS09124271Medicaid
P00113837OtherRAILROAD MEDICARE
370000373Medicare ID - Type Unspecified