Provider Demographics
NPI:1538131701
Name:ROSS, DONALD JOHN (MD)
Entity Type:Individual
Prefix:
First Name:DONALD
Middle Name:JOHN
Last Name:ROSS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1595 W COSTILLA ST
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80904-4277
Mailing Address - Country:US
Mailing Address - Phone:719-634-2479
Mailing Address - Fax:
Practice Address - Street 1:1595 W COSTILLA ST
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80904-4277
Practice Address - Country:US
Practice Address - Phone:719-634-2479
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO20277207Q00000X, 146D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Not Answered146D00000XEmergency Medical Service ProvidersPersonal Emergency Response Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
COD60883Medicare UPIN