Provider Demographics
NPI:1740352996
Name:ROSS, JOHN K (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:K
Last Name:ROSS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Middle Name:
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Mailing Address - Street 1:910 SW HWY 97
Mailing Address - Street 2:STE 104
Mailing Address - City:MADRAS
Mailing Address - State:OR
Mailing Address - Zip Code:97741
Mailing Address - Country:US
Mailing Address - Phone:541-475-1193
Mailing Address - Fax:541-475-1195
Practice Address - Street 1:1350 NE 122ND AVE STE 100
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97230-2011
Practice Address - Country:US
Practice Address - Phone:503-408-7010
Practice Address - Fax:503-408-7035
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-14
Last Update Date:2023-05-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
ORMD23430207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR287545Medicaid
ORR137896Medicare PIN
OR287545Medicaid