Provider Demographics
NPI:1184629271
Name:GROSS, FREDRIC JAY (MD)
Entity Type:Individual
Prefix:
First Name:FREDRIC
Middle Name:JAY
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:PO BOX 1290
Mailing Address - Street 2:
Mailing Address - City:FOREST
Mailing Address - State:VA
Mailing Address - Zip Code:24551-1290
Mailing Address - Country:US
Mailing Address - Phone:434-385-5600
Mailing Address - Fax:
Practice Address - Street 1:109 WIMBLEDON SQ
Practice Address - Street 2:STE E
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23320-4945
Practice Address - Country:US
Practice Address - Phone:757-547-9830
Practice Address - Fax:757-548-0721
Is Sole Proprietor?:No
Enumeration Date:2005-06-16
Last Update Date:2021-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101046621207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA058244OtherANTHEM BC/BS
VA15510OtherOPTIMA
VA180016154OtherRR MEDIACRE
VA6306616Medicaid
VA0800124OtherUNITED HEALTH CARE
NC890512XOtherNC MEDICAID
VA0800124OtherUNITED HEALTH CARE
VA15510OtherOPTIMA