Provider Demographics
NPI:1073561098
Name:GROSSMAN, GERALD (MD)
Entity Type:Individual
Prefix:
First Name:GERALD
Middle Name:
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 1:935 S SUNSET AVE
Mailing Address - Street 2:
Mailing Address - City:WEST COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91790-3408
Mailing Address - Country:US
Mailing Address - Phone:805-522-5940
Mailing Address - Fax:805-522-6401
Practice Address - Street 1:935 S SUNSET AVE
Practice Address - Street 2:
Practice Address - City:WEST COVINA
Practice Address - State:CA
Practice Address - Zip Code:91790-3408
Practice Address - Country:US
Practice Address - Phone:323-932-5301
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2017-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG223452085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G22345Medicaid
CA00G22345Medicaid
A41547Medicare UPIN