Healthcare Provider Details

I. General information

NPI: 1427135516
Provider Name (Legal Business Name): ELLIOT MITCHELL ROSS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 11/13/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

NAVAL HOSPITAL JACKSONVILLE 2080 CHILD ST
JACKSONVILLE FL
32214-0001
US

IV. Provider business mailing address

240 ENRIQUE S SAN NICHOLAS LN APT F
TALOFOFO GU
96915-3630
US

V. Phone/Fax

Practice location:
  • Phone: 904-542-7345
  • Fax:
Mailing address:
  • Phone: 904-374-3106
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberM-2112
License Number StateGU
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number0101240369
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: