Provider Demographics
NPI:1104865898
Name:GROSS, KENNETH GARY (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:GARY
Last Name:GROSS
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 1:5222 BALBOA AVE
Mailing Address - Street 2:SIXTH FLOOR
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92117-6904
Mailing Address - Country:US
Mailing Address - Phone:858-292-5101
Mailing Address - Fax:858-292-0514
Practice Address - Street 1:5222 BALBOA AVE
Practice Address - Street 2:SIXTH FLOOR
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92117-6904
Practice Address - Country:US
Practice Address - Phone:858-292-5101
Practice Address - Fax:858-292-0514
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2008-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA37440207ND0101X, 207NS0135X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A374400Medicaid
CAA37440OtherCA STATE LICENSE
CAA28378Medicare UPIN
CAWA37440AMedicare ID - Type UnspecifiedMEDICARE ID