Healthcare Provider Details

I. General information

NPI: 1619046729
Provider Name (Legal Business Name): CHARLES ROSS D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/06/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

726 S COCKRELL HILL RD
DUNCANVILLE TX
75137-2620
US

IV. Provider business mailing address

601 CANYON DR STE 100
COPPELL TX
75019-3860
US

V. Phone/Fax

Practice location:
  • Phone: 972-780-0802
  • Fax: 972-780-7134
Mailing address:
  • Phone: 972-745-7500
  • Fax: 972-471-0700

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberJ6706
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: