Provider Demographics
NPI:1780848507
Name:ROSS, ETHAN MITCHELL (MD)
Entity Type:Individual
Prefix:DR
First Name:ETHAN
Middle Name:MITCHELL
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 1:4867 W SUNSET BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90027-5969
Mailing Address - Country:US
Mailing Address - Phone:323-783-9221
Mailing Address - Fax:
Practice Address - Street 1:4867 W SUNSET BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90027-5969
Practice Address - Country:US
Practice Address - Phone:323-783-9221
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-10
Last Update Date:2023-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD175737207P00000X
CAA104876207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine