Provider Demographics
NPI:1043309487
Name:GROSSMAN, HARRY DAVID (MD)
Entity Type:Individual
Prefix:
First Name:HARRY
Middle Name:DAVID
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 1:100 BRICK RD
Mailing Address - Street 2:SUITE 115
Mailing Address - City:MARLTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08053-2146
Mailing Address - Country:US
Mailing Address - Phone:856-983-1400
Mailing Address - Fax:856-983-1681
Practice Address - Street 1:100 BRICK RD
Practice Address - Street 2:SUITE 115
Practice Address - City:MARLTON
Practice Address - State:NJ
Practice Address - Zip Code:08053-2146
Practice Address - Country:US
Practice Address - Phone:856-983-1400
Practice Address - Fax:856-983-1681
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA65455207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7663307Medicaid
NJ7663307Medicaid
NJ012636NSAMedicare ID - Type Unspecified