Provider Demographics
NPI:1679668735
Name:ROSS, DARREL LAWRENCE (MD)
Entity Type:Individual
Prefix:
First Name:DARREL
Middle Name:LAWRENCE
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 1:6626 E 75TH ST
Mailing Address - Street 2:SUITE 500
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-2805
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7229 CLEARVISTA DR
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46256-1698
Practice Address - Country:US
Practice Address - Phone:317-621-4300
Practice Address - Fax:317-621-4366
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN010606452085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200371400Medicaid
IN000000523111OtherANTHEM BLUE CROSS
IN01060645BOtherCSR
IN01060645BOtherCSR
INM400070717Medicare PIN
IN200371400Medicaid
IN01060645BOtherCSR
INM400070717Medicare PIN
INBR8209834OtherDEA