Provider Demographics
NPI:1104972900
Name:ROSS, BRIAN DAVID (MD, PHD)
Entity type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:DAVID
Last Name:ROSS
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 PICO ST
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91105-3201
Mailing Address - Country:US
Mailing Address - Phone:626-397-5840
Mailing Address - Fax:626-397-5846
Practice Address - Street 1:10 PICO ST
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91105-3201
Practice Address - Country:US
Practice Address - Phone:626-397-5840
Practice Address - Fax:626-397-5846
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-25
Last Update Date:2010-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA053596174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG16241Medicare UPIN
CAA53596Medicare ID - Type Unspecified