Provider Demographics
NPI:1033216577
Name:GROSSMAN, MARC A (MD)
Entity Type:Individual
Prefix:DR
First Name:MARC
Middle Name:A
Last Name:GROSSMAN
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 1:340 W CENTRAL AVE
Mailing Address - Street 2:#136
Mailing Address - City:BREA
Mailing Address - State:CA
Mailing Address - Zip Code:92821
Mailing Address - Country:US
Mailing Address - Phone:714-529-1421
Mailing Address - Fax:714-256-0541
Practice Address - Street 1:340 W CENTRAL AVE
Practice Address - Street 2:#136
Practice Address - City:BREA
Practice Address - State:CA
Practice Address - Zip Code:92821-3006
Practice Address - Country:US
Practice Address - Phone:714-529-1421
Practice Address - Fax:714-256-0541
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-19
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG42011174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG42011BMedicare PIN