Provider Demographics
NPI:1205834587
Name:ROSS, WILLIE F JR (OD)
Entity Type:Individual
Prefix:
First Name:WILLIE
Middle Name:F
Last Name:ROSS
Suffix:JR
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:22 EXECUTIVE DR
Mailing Address - Street 2:
Mailing Address - City:TOMPKINSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42167-7478
Mailing Address - Country:US
Mailing Address - Phone:270-487-5741
Mailing Address - Fax:270-487-9664
Practice Address - Street 1:22 EXECUTIVE DR
Practice Address - Street 2:
Practice Address - City:TOMPKINSVILLE
Practice Address - State:KY
Practice Address - Zip Code:42167-7478
Practice Address - Country:US
Practice Address - Phone:270-487-5741
Practice Address - Fax:270-487-9664
Is Sole Proprietor?:No
Enumeration Date:2005-07-12
Last Update Date:2017-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY755DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY03322OtherSPECTERA
KY1386776169Medicaid
KY77007557Medicaid
KY8846OtherMEDICARE P-10
KY1205834587Medicaid
KY000000199526OtherBCBS
410049288OtherRAILROAD MEDICINE
KY1386776169OtherMEDICARE CORP
KY5940OtherDAVIS VISION
KY8846OtherMEDICARE P-10