Provider Demographics
NPI:1497872659
Name:ROSS, MITCHELL J (MD)
Entity Type:Individual
Prefix:DR
First Name:MITCHELL
Middle Name:J
Last Name:ROSS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:40 E PUTNAM AVE
Mailing Address - Street 2:
Mailing Address - City:COS COB
Mailing Address - State:CT
Mailing Address - Zip Code:06807-2600
Mailing Address - Country:US
Mailing Address - Phone:206-869-3439
Mailing Address - Fax:203-869-4206
Practice Address - Street 1:40 E PUTNAM AVE
Practice Address - Street 2:
Practice Address - City:COS COB
Practice Address - State:CT
Practice Address - Zip Code:06807-2600
Practice Address - Country:US
Practice Address - Phone:206-869-3439
Practice Address - Fax:203-869-4206
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CT031394207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology