Provider Demographics
NPI:1124326012
Name:ROSS, KENNETH LAWRENCE (MD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:LAWRENCE
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 1:785 NE 33RD ST
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33431-6127
Mailing Address - Country:US
Mailing Address - Phone:561-750-1130
Mailing Address - Fax:561-750-1130
Practice Address - Street 1:785 NE 33RD ST
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33431-6127
Practice Address - Country:US
Practice Address - Phone:561-750-1130
Practice Address - Fax:561-750-1130
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-02
Last Update Date:2011-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME92269207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
B78595Medicare UPIN