Provider Demographics
NPI:1366524993
Name:TATUM, ROSS (MD)
Entity type:Individual
Prefix:DR
First Name:ROSS
Middle Name:
Last Name:TATUM
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 1:3815 LISBON ST STE 200
Mailing Address - Street 2:
Mailing Address - City:FT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76107-5673
Mailing Address - Country:US
Mailing Address - Phone:817-989-1122
Mailing Address - Fax:817-989-2072
Practice Address - Street 1:3815 LISBON ST STE 200
Practice Address - Street 2:
Practice Address - City:FT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76107-5673
Practice Address - Country:US
Practice Address - Phone:817-989-1122
Practice Address - Fax:817-989-2072
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-20
Last Update Date:2014-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ03032084P0800X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP000T42H2Medicaid
TXP000T42H2Medicaid
TX00T42HMedicare ID - Type Unspecified