Provider Demographics
NPI:1841206307
Name:ROSS, TIMOTHY TODD (MD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:TODD
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 1:11500 NE 76TH ST STE A3
Mailing Address - Street 2:PMB 7
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98662-3901
Mailing Address - Country:US
Mailing Address - Phone:360-254-3663
Mailing Address - Fax:
Practice Address - Street 1:715 S ANDRESEN RD
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98661-7603
Practice Address - Country:US
Practice Address - Phone:360-693-7877
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2014-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00019932207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR0000BKBVKMedicare PIN
WAG000615248Medicare PIN