Provider Demographics
NPI:1215928221
Name:ROSS, CRAIG A (MD)
Entity type:Individual
Prefix:DR
First Name:CRAIG
Middle Name:A
Last Name:ROSS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 4166
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92605-4166
Mailing Address - Country:US
Mailing Address - Phone:714-775-0777
Mailing Address - Fax:714-775-1026
Practice Address - Street 1:16480 HARBOR BLVD
Practice Address - Street 2:SUITE 104
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708-1361
Practice Address - Country:US
Practice Address - Phone:714-775-0777
Practice Address - Fax:714-775-1026
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG282252084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G282250Medicaid
CAG28225Medicare ID - Type Unspecified
CA00G282250Medicaid