Provider Demographics
NPI:1962420810
Name:ROSS, SHEA O (MD)
Entity type:Individual
Prefix:
First Name:SHEA
Middle Name:O
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 1:6400 W NEWBERRY RD
Mailing Address - Street 2:STE 308
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32605
Mailing Address - Country:US
Mailing Address - Phone:352-331-8902
Mailing Address - Fax:
Practice Address - Street 1:6400 W NEWBERRY RD
Practice Address - Street 2:STE 302
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32605
Practice Address - Country:US
Practice Address - Phone:352-331-8902
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2020-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0070530207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL261444800Medicaid
58801Medicare ID - Type Unspecified