Provider Demographics
NPI:1598979288
Name:ROSS, GERALD L (OD)
Entity Type:Individual
Prefix:DR
First Name:GERALD
Middle Name:L
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 1:1622 W OREGON AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19145-4543
Mailing Address - Country:US
Mailing Address - Phone:215-755-6820
Mailing Address - Fax:215-755-9706
Practice Address - Street 1:1622 W OREGON AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19145-4543
Practice Address - Country:US
Practice Address - Phone:215-755-6820
Practice Address - Fax:215-755-9706
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOET008972152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA01406655Medicaid