Provider Demographics
NPI:1922150515
Name:ROSS, RANDALL (MD)
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:
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 1:19 STONEYSIDE DR
Mailing Address - Street 2:
Mailing Address - City:LARCHMONT
Mailing Address - State:NY
Mailing Address - Zip Code:10538-1417
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15 W 12TH ST
Practice Address - Street 2:SUITE 1F
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10011-8546
Practice Address - Country:US
Practice Address - Phone:212-352-3354
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-17
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1708112084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY48F471Medicare UPIN