MEDICARE: WILLIE F ROSS JR. O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	755DT	KY

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
4	8846	OTHER	KY	MEDICARE P-10
8	1386776169	OTHER	KY	MEDICARE CORP

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	03322	OTHER	KY	SPECTERA
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
6	000000199526	OTHER	KY	BCBS
7	410049288	OTHER		RAILROAD MEDICINE
9	5940	OTHER	KY	DAVIS VISION

General Provider Information

NPI Number	:	1205834587
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WILLIE F ROSS JR. O.D.

Provider Business Mailing Address
First Line	:	22 EXECUTIVE DR
Second Line	:
City	:	TOMPKINSVILLE
State	:	KY
Zip	:	42167-7478
Country	:	US
Telephone Number	:	270-487-5741
Fax Number	:	270-487-9664

Provider Business Practice Location Address
First Line	:	22 EXECUTIVE DR
Second Line	:
City	:	TOMPKINSVILLE
State	:	KY
Zip	:	42167-7478
Country	:	US
Telephone Number	:	270-487-5741
Fax Number	:	270-487-9664

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/12/2005
Last Update Date	:	01/10/2017

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