Provider Demographics
NPI:1598752982
Name:ROSS, FRED HENRY (MD)
Entity Type:Individual
Prefix:
First Name:FRED
Middle Name:HENRY
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 1:1612 W PLAZA DR
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32308-5324
Mailing Address - Country:US
Mailing Address - Phone:850-878-8899
Mailing Address - Fax:850-656-2098
Practice Address - Street 1:1612 W PLAZA DR
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-5324
Practice Address - Country:US
Practice Address - Phone:850-878-8899
Practice Address - Fax:850-656-2098
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-30
Last Update Date:2015-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME44955207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL20066Medicare ID - Type Unspecified
FLD53403Medicare UPIN
FL069705200Medicaid