Healthcare Provider Details

I. General information

NPI: 1386785657
Provider Name (Legal Business Name): CAROLYN COKER ROSS M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/09/2007
Last Update Date: 05/15/2025
Certification Date: 05/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3940 DOVE ST UNIT 207
SAN DIEGO CA
92103-2961
US

IV. Provider business mailing address

8775 AERO DR STE 238
SAN DIEGO CA
92123-1756
US

V. Phone/Fax

Practice location:
  • Phone: 520-440-0079
  • Fax: 855-651-2323
Mailing address:
  • Phone: 619-930-9524
  • Fax: 619-269-9245

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083A0300X
TaxonomyAddiction Medicine (Preventive Medicine) Physician
License NumberA37347
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: