Healthcare Provider Details

I. General information

NPI: 1194712208
Provider Name (Legal Business Name): JONATHAN ROSS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2005
Last Update Date: 04/14/2021
Certification Date: 04/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6410 ROCKLEDGE DR STE 610
BETHESDA MD
20817-1844
US

IV. Provider business mailing address

6410 ROCKLEDGE DR STE 610
BETHESDA MD
20817-1844
US

V. Phone/Fax

Practice location:
  • Phone: 301-530-9745
  • Fax: 301-530-0046
Mailing address:
  • Phone: 301-530-9745
  • Fax: 301-530-0046

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number10401
License Number StateNH
# 2
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberD83244
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number79897
License Number StateMA
# 4
Primary TaxonomyN
Taxonomy Code2084N0600X
TaxonomyClinical Neurophysiology Physician
License Number79897
License Number StateMA
# 5
Primary TaxonomyN
Taxonomy Code2084N0600X
TaxonomyClinical Neurophysiology Physician
License Number10401
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: