Provider Demographics
NPI:1215071766
Name:ROSS, JEFFREY M (MD)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:M
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 1:1670 CERRO GORDO RD
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87501-6175
Mailing Address - Country:US
Mailing Address - Phone:505-988-4349
Mailing Address - Fax:505-989-7492
Practice Address - Street 1:1670 CERRO GORDO RD
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87501-6175
Practice Address - Country:US
Practice Address - Phone:505-988-4349
Practice Address - Fax:505-989-7492
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-17
Last Update Date:2008-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM87-1412084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM3087Medicaid
NMC08515Medicare UPIN
NM3087Medicaid
NM$$$$$$$$$Medicare PIN