Provider Demographics
NPI:1437141512
Name:ROSS, RICHARD M (OD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:M
Last Name:ROSS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1708 LEE RD
Mailing Address - Street 2:
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32789-2160
Mailing Address - Country:US
Mailing Address - Phone:407-629-1174
Mailing Address - Fax:407-629-6117
Practice Address - Street 1:1708 LEE RD
Practice Address - Street 2:
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32789-2160
Practice Address - Country:US
Practice Address - Phone:407-629-1174
Practice Address - Fax:407-629-6117
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-16
Last Update Date:2011-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1553152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL19734Medicare PIN
FLTO2004Medicare UPIN