=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679535470
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOHN P ROSS MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/05/2006
-----------------------------------------------------
Last Update Date | 04/03/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 14104 N. EASTERN AVE. STE. E
-----------------------------------------------------
City | EDMOND
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73013
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-340-1279
-----------------------------------------------------
Fax | 405-216-5089
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1211 N SHARTEL AVE STE 200
-----------------------------------------------------
City | OKLAHOMA CITY
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73103-2425
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-235-8008
-----------------------------------------------------
Fax | 405-239-2403
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208800000X
-----------------------------------------------------
Taxonomy Name | Urology Physician
-----------------------------------------------------
License Number | MD-45914
-----------------------------------------------------
License Number State | IA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208800000X
-----------------------------------------------------
Taxonomy Name | Urology Physician
-----------------------------------------------------
License Number | 13842
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------