Provider Demographics
NPI:1871536342
Name:ROSS, WILLIE VAN (MD)
Entity type:Individual
Prefix:DR
First Name:WILLIE
Middle Name:VAN
Last Name:ROSS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:22290 FOOTHILL BLVD
Mailing Address - Street 2:1
Mailing Address - City:HAYWARD
Mailing Address - State:CA
Mailing Address - Zip Code:94541-2731
Mailing Address - Country:US
Mailing Address - Phone:510-581-1446
Mailing Address - Fax:510-518-1805
Practice Address - Street 1:22290 FOOTHILL BLVD
Practice Address - Street 2:1
Practice Address - City:HAYWARD
Practice Address - State:CA
Practice Address - Zip Code:94541-2731
Practice Address - Country:US
Practice Address - Phone:510-581-1446
Practice Address - Fax:510-518-1805
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2013-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG53544174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0067540Medicaid
CAGR0067540Medicaid