Provider Demographics
NPI:1174552996
Name:ROSS, MONIQUE BURNETTE (MD)
Entity type:Individual
Prefix:
First Name:MONIQUE
Middle Name:BURNETTE
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 1:1600 EUREKA RD
Mailing Address - Street 2:KAISER PERMANENTE MEDICAL GROUP
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95661-3027
Mailing Address - Country:US
Mailing Address - Phone:916-784-4050
Mailing Address - Fax:916-746-4314
Practice Address - Street 1:1600 EUREKA RD
Practice Address - Street 2:KAISER PERMANENTE MEDICAL GROUP
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-3027
Practice Address - Country:US
Practice Address - Phone:916-784-4050
Practice Address - Fax:916-746-4314
Is Sole Proprietor?:No
Enumeration Date:2006-07-02
Last Update Date:2021-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA49778207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A497780OtherMEDI CAL
F76122Medicare UPIN
00A497780Medicare ID - Type Unspecified