Provider Demographics
NPI:1033116439
Name:GROSS, GARY EDWARD (MD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:EDWARD
Last Name:GROSS
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 1:825 MEDICAL DR
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701-2143
Mailing Address - Country:US
Mailing Address - Phone:903-597-2273
Mailing Address - Fax:903-597-2466
Practice Address - Street 1:825 MEDICAL DR
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-2143
Practice Address - Country:US
Practice Address - Phone:903-597-2273
Practice Address - Fax:903-597-2466
Is Sole Proprietor?:No
Enumeration Date:2005-06-30
Last Update Date:2014-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE9671207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX128154506Medicaid
TX128154506Medicaid
C16331Medicare UPIN