Provider Demographics
NPI:1063890697
Name:ROSS, JEREMY MICHAEL (MD)
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:MICHAEL
Last Name:ROSS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:333 S 38TH ST STE A
Mailing Address - Street 2:
Mailing Address - City:MUSKOGEE
Mailing Address - State:OK
Mailing Address - Zip Code:74401-4937
Mailing Address - Country:US
Mailing Address - Phone:918-682-8631
Mailing Address - Fax:918-686-7078
Practice Address - Street 1:333 S 38TH ST STE A
Practice Address - Street 2:
Practice Address - City:MUSKOGEE
Practice Address - State:OK
Practice Address - Zip Code:74401-4937
Practice Address - Country:US
Practice Address - Phone:918-682-8631
Practice Address - Fax:918-686-7078
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-14
Last Update Date:2018-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK31424207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200595230Medicaid