Provider Demographics
NPI:1740275932
Name:ROSS, CHARLES S (DO)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:S
Last Name:ROSS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3910 MIRROR POND WAY
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97408-5954
Mailing Address - Country:US
Mailing Address - Phone:541-680-0361
Mailing Address - Fax:541-200-6530
Practice Address - Street 1:3910 MIRROR POND WAY
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97408-5954
Practice Address - Country:US
Practice Address - Phone:541-680-0361
Practice Address - Fax:541-200-6530
Is Sole Proprietor?:No
Enumeration Date:2005-09-14
Last Update Date:2025-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDO10012207P00000X, 208D00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR165878Medicaid
OR1740275932Medicaid
OR000188024OtherBCBS
OR168395Medicaid
R103163OtherMEDICARE PART B
132257Medicare ID - Type Unspecified
OR168395Medicaid