Provider Demographics
NPI:1053462606
Name:GROSSMAN, ROBERT A (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
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 1:558 VENTU PARK RD STE A
Mailing Address - Street 2:
Mailing Address - City:THOUSAND OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91320-2752
Mailing Address - Country:US
Mailing Address - Phone:818-817-9832
Mailing Address - Fax:818-817-9835
Practice Address - Street 1:558 VENTU PARK RD STE A
Practice Address - Street 2:
Practice Address - City:THOUSAND OAKS
Practice Address - State:CA
Practice Address - Zip Code:91320-2752
Practice Address - Country:US
Practice Address - Phone:818-817-9832
Practice Address - Fax:818-817-9835
Is Sole Proprietor?:No
Enumeration Date:2007-01-12
Last Update Date:2014-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG039997207VX0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWG39997BMedicare PIN
CAA92148Medicare UPIN