Provider Demographics
NPI:1225196132
Name:JONATHAN B. ROSS OD PA
Entity Type:Organization
Organization Name:JONATHAN B. ROSS OD PA
Other - Org Name:ROSS VISION CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:BLAKE
Authorized Official - Last Name:ROSS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:870-931-2020
Mailing Address - Street 1:1815 E HIGHLAND DR
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72401-6118
Mailing Address - Country:US
Mailing Address - Phone:870-931-2020
Mailing Address - Fax:870-932-8004
Practice Address - Street 1:1815 E HIGHLAND DR
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-6118
Practice Address - Country:US
Practice Address - Phone:870-931-2020
Practice Address - Fax:870-932-8004
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-04
Last Update Date:2009-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2493152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR142832722Medicaid
AR5F545OtherAR BLUE CROSS BLUE SHIELD
AR5F545OtherAR BLUE CROSS BLUE SHIELD