Provider Demographics
NPI:1902302334
Name:ROSS, BENJAMIN (MD)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:
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 1:12040 NE 128TH ST # MS 105
Mailing Address - Street 2:
Mailing Address - City:KIRKLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98034-3013
Mailing Address - Country:US
Mailing Address - Phone:425-899-2560
Mailing Address - Fax:425-899-2079
Practice Address - Street 1:1959 NE PACIFIC STREET
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98185-0001
Practice Address - Country:US
Practice Address - Phone:307-752-1605
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-04
Last Update Date:2022-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAML60861759207R00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NONEOtherNONE