Provider Demographics
NPI:1104935030
Name:ROSS, JOHNNY SHANE (MD)
Entity type:Individual
Prefix:
First Name:JOHNNY
Middle Name:SHANE
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:PO BOX 844658
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-4658
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2401 S 31ST ST BLDG 35
Practice Address - Street 2:
Practice Address - City:TEMPLE
Practice Address - State:TX
Practice Address - Zip Code:76508-4200
Practice Address - Country:US
Practice Address - Phone:254-724-2111
Practice Address - Fax:512-263-4506
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2024-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ6036208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0479743 02Medicaid
TXJ6036OtherTX LICENSURE MEDICAL BOARD
142726600OtherUS DEPARTMENT OF LABOR
142726600OtherUS DEPARTMENT OF LABOR