Provider Demographics
NPI:1710250253
Name:ROSS, MARK TIMOTHY (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:TIMOTHY
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 1:3737 N 970 E
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-5247
Mailing Address - Country:US
Mailing Address - Phone:801-360-5774
Mailing Address - Fax:801-226-2669
Practice Address - Street 1:3737 N 970 E
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-5247
Practice Address - Country:US
Practice Address - Phone:801-360-5774
Practice Address - Fax:801-226-2669
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-14
Last Update Date:2012-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT177939-1205207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine