Provider Demographics
NPI:1144213786
Name:ROSS, BRIAN MATTHEW (OD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:MATTHEW
Last Name:ROSS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:9795 CROSSPOINT BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46256-3354
Mailing Address - Country:US
Mailing Address - Phone:317-254-6480
Mailing Address - Fax:317-259-8609
Practice Address - Street 1:643 OHIO ST
Practice Address - Street 2:
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47807-3525
Practice Address - Country:US
Practice Address - Phone:812-232-0073
Practice Address - Fax:812-232-0074
Is Sole Proprietor?:No
Enumeration Date:2005-08-30
Last Update Date:2014-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18003235A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200444580Medicaid
IN894060007Medicare PIN
INU95679Medicare UPIN
IN200444580Medicaid
IN5468990001Medicare NSC