Provider Demographics
NPI:1942380506
Name:ROSS, JACK A (MD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:A
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:PO BOX 560977
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32956-0977
Mailing Address - Country:US
Mailing Address - Phone:321-639-2404
Mailing Address - Fax:
Practice Address - Street 1:742 S US 1
Practice Address - Street 2:
Practice Address - City:COCOA
Practice Address - State:FL
Practice Address - Zip Code:32922-3723
Practice Address - Country:US
Practice Address - Phone:321-639-2404
Practice Address - Fax:321-636-0240
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2009-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME38787207L00000X
FL261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL068638700Medicaid
FL05499Medicare ID - Type Unspecified