Provider Demographics
NPI:1528072188
Name:ROSS, THERESA J (MD)
Entity type:Individual
Prefix:DR
First Name:THERESA
Middle Name:J
Last Name:ROSS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 DESIARD ST
Mailing Address - Street 2:SUITE 355
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71201-7319
Mailing Address - Country:US
Mailing Address - Phone:318-807-7875
Mailing Address - Fax:318-812-6603
Practice Address - Street 1:112 SAINT JOHN ST
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201-7322
Practice Address - Country:US
Practice Address - Phone:318-387-5681
Practice Address - Fax:318-322-9957
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2019-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA017867208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1342106Medicaid
LA5M439DD24Medicare PIN
LA1342106Medicaid