Provider Demographics
NPI:1649700527
Name:ROSS, CLINTON (MD)
Entity type:Individual
Prefix:DR
First Name:CLINTON
Middle Name:
Last Name:ROSS
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2686 NEWBERRY STATION DR
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70611-3984
Mailing Address - Country:US
Mailing Address - Phone:337-485-7600
Mailing Address - Fax:
Practice Address - Street 1:2686 NEWBERRY STATION DR
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70611-3984
Practice Address - Country:US
Practice Address - Phone:337-485-7600
Practice Address - Fax:337-485-7700
Is Sole Proprietor?:No
Enumeration Date:2017-06-14
Last Update Date:2025-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME1613042084P0800X
LA3097492084P0800X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1551228Medicaid
1063569648OtherGROUP NPI
LA2470299Medicaid
FL119512900Medicaid