Healthcare Provider Details

I. General information

NPI: 1316301914
Provider Name (Legal Business Name): NICOLE ROSS M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/08/2016
Last Update Date: 04/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4650 W SUNSET BLVD
LOS ANGELES CA
90027-6062
US

IV. Provider business mailing address

421 LINCOLN BLVD
SANTA MONICA CA
90402-1935
US

V. Phone/Fax

Practice location:
  • Phone: 323-361-2122
  • Fax:
Mailing address:
  • Phone: 310-871-7221
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number141736
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: