Basic Information
Provider Information | |||||||||
NPI: | 1861492498 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ROSS-JOHNSON | ||||||||
FirstName: | ANGELA | ||||||||
MiddleName: | Y | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 6101 BLUE LAGOON DR STE 400 | ||||||||
Address2: |   | ||||||||
City: | MIAMI | ||||||||
State: | FL | ||||||||
PostalCode: | 331262051 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3055002027 | ||||||||
FaxNumber: | 3055002155 | ||||||||
Practice Location | |||||||||
Address1: | 3854 BRITTON PLZ | ||||||||
Address2: |   | ||||||||
City: | TAMPA | ||||||||
State: | FL | ||||||||
PostalCode: | 336111406 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8138372814 | ||||||||
FaxNumber: | 8138394336 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/26/2005 | ||||||||
LastUpdateDate: | 12/16/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 12/16/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 173000000X | 13200 | AL | N |   | Other Service Providers | Legal Medicine |   | 207Q00000X | ME99356 | FL | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 000019820 | 05 | AL |   | MEDICAID | ME 99356 | 01 | FL | MEDICAL LICENSE NUMBER | OTHER |