Provider Demographics
NPI:1821041930
Name:ROSS, KRISTINA DAWN (OD)
Entity Type:Individual
Prefix:
First Name:KRISTINA
Middle Name:DAWN
Last Name:ROSS
Suffix:
Gender:F
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:PO BOX 119
Mailing Address - Street 2:
Mailing Address - City:JONESVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47247-0119
Mailing Address - Country:US
Mailing Address - Phone:812-523-6787
Mailing Address - Fax:812-523-6969
Practice Address - Street 1:1600 E TIPTON ST
Practice Address - Street 2:
Practice Address - City:SEYMOUR
Practice Address - State:IN
Practice Address - Zip Code:47274-3560
Practice Address - Country:US
Practice Address - Phone:812-523-6787
Practice Address - Fax:812-523-6969
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2007-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18002723A & B152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN494430Medicare ID - Type Unspecified
U58921Medicare UPIN