Provider Demographics
NPI:1316020829
Name:ROSS, ALICIA MENDEZ (MD)
Entity Type:Individual
Prefix:DR
First Name:ALICIA
Middle Name:MENDEZ
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 478
Mailing Address - Street 2:
Mailing Address - City:ENFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06083-0478
Mailing Address - Country:US
Mailing Address - Phone:860-763-3864
Mailing Address - Fax:
Practice Address - Street 1:575 BEECH ST
Practice Address - Street 2:
Practice Address - City:HOLYOKE
Practice Address - State:MA
Practice Address - Zip Code:01040-2223
Practice Address - Country:US
Practice Address - Phone:413-534-2543
Practice Address - Fax:413-534-2655
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA34125207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1200798Medicaid
MA6288726002OtherCIGNA
MA034125OtherTUFTS
MAH10136OtherBLUE CROSS
CT034125OtherCONNECTICARE
MAH0600004Medicare ID - Type Unspecified
MA1200798Medicaid