Basic Information
| Provider Information | |||||||||
| NPI: | 1033143615 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROSS | ||||||||
| FirstName: | TIMOTHY | ||||||||
| MiddleName: | ADKINS | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | OD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 4521 17TH AVE | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 31904 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7066600191 | ||||||||
| FaxNumber: | 7065968388 | ||||||||
| Practice Location | |||||||||
| Address1: | 4521 17TH AVE | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 31904 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7066600191 | ||||||||
| FaxNumber: | 7065968388 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2006 | ||||||||
| LastUpdateDate: | 06/03/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152WC0802X | OPT001089 | GA | N | Eye and Vision Services Providers | Optometrist | Corneal and Contact Management | 152WL0500X | OPT001089 | GA | N | Eye and Vision Services Providers | Optometrist | Low Vision Rehabilitation | 152WP0200X | OPT001089 | GA | N | Eye and Vision Services Providers | Optometrist | Pediatrics | 152WS0006X | OPT001089 | GA | N | Eye and Vision Services Providers | Optometrist | Sports Vision | 152WV0400X | OPT001089 | GA | N | Eye and Vision Services Providers | Optometrist | Vision Therapy | 152WX0102X | OPT001089 | GA | N | Eye and Vision Services Providers | Optometrist | Occupational Vision | 152W00000X | OPT001089 | GA | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 1107013 | 01 | GA | UNITED HEALTHCARE | OTHER | 11473020 | 01 | CAQH | OTHER | 00584075A | 05 | GA | MEDICAID |