Provider Demographics
NPI:1770873796
Name:FLAKE, ROSS DARRELL (DO)
Entity type:Individual
Prefix:DR
First Name:ROSS
Middle Name:DARRELL
Last Name:FLAKE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:LANSTUHL REGIONAL MEDICAL CENTER
Mailing Address - Street 2:UNIT 3310,0
Mailing Address - City:APO
Mailing Address - State:AE
Mailing Address - Zip Code:09180
Mailing Address - Country:US
Mailing Address - Phone:801-362-7872
Mailing Address - Fax:
Practice Address - Street 1:LANSTUHL REGIONAL MEDICAL CENTER
Practice Address - Street 2:UNIT 3310,0
Practice Address - City:APO
Practice Address - State:AE
Practice Address - Zip Code:09180-3100
Practice Address - Country:US
Practice Address - Phone:801-362-7872
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-11
Last Update Date:2023-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1770873796208D00000X
390200000X
NE1036208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program