Provider Demographics
NPI:1083751366
Name:GROSSMAN, JEFFREY WAYNE (MD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:WAYNE
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 1:22100 BOTHELL EVERETT HWY
Mailing Address - Street 2:
Mailing Address - City:BOTHELL
Mailing Address - State:WA
Mailing Address - Zip Code:98021-8431
Mailing Address - Country:US
Mailing Address - Phone:855-687-7237
Mailing Address - Fax:855-673-9190
Practice Address - Street 1:2031 E MOUNTAIN VISTA DR
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83815-9683
Practice Address - Country:US
Practice Address - Phone:208-570-3342
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2023-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-102762085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology