Provider Demographics
NPI:1104935808
Name:ROSS, VINCENT LUCIANO (MD)
Entity type:Individual
Prefix:MR
First Name:VINCENT
Middle Name:LUCIANO
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 1:442 N MAIN AVE
Mailing Address - Street 2:
Mailing Address - City:SCRANTON
Mailing Address - State:PA
Mailing Address - Zip Code:18504
Mailing Address - Country:US
Mailing Address - Phone:570-347-5605
Mailing Address - Fax:570-347-5606
Practice Address - Street 1:442 N MAIN AVE
Practice Address - Street 2:
Practice Address - City:SCRANTON
Practice Address - State:PA
Practice Address - Zip Code:18504
Practice Address - Country:US
Practice Address - Phone:570-347-5605
Practice Address - Fax:570-347-5606
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD009571E208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA35025OtherESPN
PA1400787Medicaid
PA35025OtherESPN