Provider Demographics
NPI:1033193511
Name:GROSS, DOUGLAS (OD)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:
Last Name:GROSS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:207 COUNTY ROAD 120
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303-4872
Mailing Address - Country:US
Mailing Address - Phone:320-202-5985
Mailing Address - Fax:320-202-7890
Practice Address - Street 1:207 COUNTY ROAD 120
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-4872
Practice Address - Country:US
Practice Address - Phone:320-202-5985
Practice Address - Fax:320-202-7890
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-30
Last Update Date:2010-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2083152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN078223800Medicaid
MN410032600OtherRAILROAD MEDICARE
MN82973GROtherBLUE CROSS BLUE SHIELD
MN22-24009OtherMEDICA
MNHP27094OtherHEALTH PARTNERS
MN078223800Medicaid
MN419000618Medicare PIN