Provider Demographics
NPI:1174623292
Name:ROSS, MARK D (OD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:D
Last Name:ROSS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 266
Mailing Address - Street 2:
Mailing Address - City:SCOTTSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42164-0266
Mailing Address - Country:US
Mailing Address - Phone:270-237-3871
Mailing Address - Fax:270-237-5057
Practice Address - Street 1:330 FRANKLIN RD
Practice Address - Street 2:
Practice Address - City:SCOTTSVILLE
Practice Address - State:KY
Practice Address - Zip Code:42164-8805
Practice Address - Country:US
Practice Address - Phone:270-237-3871
Practice Address - Fax:270-237-5057
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-25
Last Update Date:2008-07-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1244DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY0000053704OtherBCBS
KY77012441Medicaid
KY1973001Medicare PIN
KY1143350001Medicare NSC
KY0000053704OtherBCBS