Provider Demographics
NPI:1699919795
Name:ROSS, CHARLES J (IDMT)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:J
Last Name:ROSS
Suffix:
Gender:M
Credentials:IDMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5809 IVANHOE CT APT 18
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28314-4461
Mailing Address - Country:US
Mailing Address - Phone:253-381-7108
Mailing Address - Fax:
Practice Address - Street 1:5809 IVANHOE CT APT 18
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28314-4461
Practice Address - Country:US
Practice Address - Phone:253-381-7108
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-21
Last Update Date:2009-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians