Healthcare Provider Details

I. General information

NPI: 1215071766
Provider Name (Legal Business Name): JEFFREY M ROSS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/17/2007
Last Update Date: 11/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1670 CERRO GORDO RD
SANTA FE NM
87501-6175
US

IV. Provider business mailing address

1670 CERRO GORDO RD
SANTA FE NM
87501-6175
US

V. Phone/Fax

Practice location:
  • Phone: 505-988-4349
  • Fax: 505-989-7492
Mailing address:
  • Phone: 505-988-4349
  • Fax: 505-989-7492

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number87-141
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: