Provider Demographics
NPI:1114997731
Name:ROSS, THOMAS W (DO)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:W
Last Name:ROSS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 4557
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50305-4557
Mailing Address - Country:US
Mailing Address - Phone:515-280-7004
Mailing Address - Fax:515-280-9525
Practice Address - Street 1:1000 E. ARMY POST RD
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50315-5939
Practice Address - Country:US
Practice Address - Phone:515-953-7560
Practice Address - Fax:515-953-7549
Is Sole Proprietor?:No
Enumeration Date:2006-01-25
Last Update Date:2012-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA03119207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA220459Medicaid
21062Medicare PIN
IA220459Medicaid