Provider Demographics
NPI:1821110321
Name:ROSS, RANDY RAYMOND (MD)
Entity Type:Individual
Prefix:
First Name:RANDY
Middle Name:RAYMOND
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 1:7408 E PINTO WAY
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92869-4525
Mailing Address - Country:US
Mailing Address - Phone:714-532-4121
Mailing Address - Fax:
Practice Address - Street 1:7408 E PINTO WAY
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92869-4525
Practice Address - Country:US
Practice Address - Phone:714-532-4121
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-04
Last Update Date:2010-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG689552084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G689551Medicaid
CA00G689551Medicaid