Provider Demographics
NPI:1538163506
Name:ROSS, DANIEL WAYNE (MD)
Entity type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:WAYNE
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 1:200 CORPORATE BLVD
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70508-3870
Mailing Address - Country:US
Mailing Address - Phone:800-893-9698
Mailing Address - Fax:
Practice Address - Street 1:1408 LAKE RIDGE SQ
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37601-7407
Practice Address - Country:US
Practice Address - Phone:423-782-6848
Practice Address - Fax:423-283-4797
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-08
Last Update Date:2018-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0000037770207Q00000X
TN37770207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1538163506Medicaid
TN3890168Medicaid
TN1515615Medicaid
VA1538163506Medicaid
TN3890168Medicaid
TN103I936126Medicare PIN