MEDICARE: OLIVER ROSS

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	174400000X	Specialist	CL1310861	FL

General Provider Information

NPI Number	:	1538915798
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	OLIVER ROSS

Provider Business Mailing Address
First Line	:	933 W INTERNATIONAL SPEEDWAY BLVD
Second Line	:
City	:	DAYTONA BEACH
State	:	FL
Zip	:	32114-3566
Country	:	US
Telephone Number	:	386-295-0786
Fax Number	:

Provider Business Practice Location Address
First Line	:	2090 S NOVA RD STE A127
Second Line	:
City	:	SOUTH DAYTONA
State	:	FL
Zip	:	32119-8841
Country	:	US
Telephone Number	:	386-341-6256
Fax Number	:

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

Provider Enumeration Date	:	04/29/2024
Last Update Date	:	04/29/2024

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Directions to “ OLIVER ROSS ” Practice Location

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