Basic Information
| Provider Information | |||||||||
| NPI: | 1700959715 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROSS | ||||||||
| FirstName: | THEODORA | ||||||||
| MiddleName: | SUZANNE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | P.O. BOX 845347 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752845347 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2146454673 | ||||||||
| FaxNumber: | 2146452610 | ||||||||
| Practice Location | |||||||||
| Address1: | 5323 HARRY HINES BLVD. | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 753907208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2146454673 | ||||||||
| FaxNumber: | 2146452610 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2006 | ||||||||
| LastUpdateDate: | 10/15/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 4301075061 | MI | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RH0000X | 4301075061 | MI | N | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology | 207RX0202X | 4301075061 | MI | N | Allopathic & Osteopathic Physicians | Internal Medicine | Medical Oncology | 207RH0003X | P2161 | TX | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology | 207R00000X | P2161 | TX | N | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 4129067 | 05 | MI | MEDICAID | TXB147854 | 01 | TX | MEDICARE ID/TYPE UNSPECIFIED | OTHER | 295867001 | 05 | TX | MEDICAID |