Provider Demographics
NPI:1295730323
Name:ROSS, PETER WELLS (MD)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:WELLS
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 1:208 GASLIGHT BLVD
Mailing Address - Street 2:
Mailing Address - City:LUFKIN
Mailing Address - State:TX
Mailing Address - Zip Code:75904-3166
Mailing Address - Country:US
Mailing Address - Phone:936-634-8800
Mailing Address - Fax:936-634-8836
Practice Address - Street 1:208 GASLIGHT BLVD
Practice Address - Street 2:
Practice Address - City:LUFKIN
Practice Address - State:TX
Practice Address - Zip Code:75904-3166
Practice Address - Country:US
Practice Address - Phone:936-634-8800
Practice Address - Fax:936-634-8836
Is Sole Proprietor?:No
Enumeration Date:2005-06-15
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXQ2944207X00000X
AK4926173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No173000000XOther Service ProvidersLegal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMD 4926Medicaid
AKMD4926Medicaid
AKMD4926Medicaid
AKBR7842556OtherDEA REGISTRATION
AK152303Medicare ID - Type Unspecified