Provider Demographics
NPI:1184684672
Name:GROSSMAN, KENNETH RANDELL (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:RANDELL
Last Name:GROSSMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:RANDY
Other - Middle Name:
Other - Last Name:GROSSMAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:580 COLLINS DR
Mailing Address - Street 2:
Mailing Address - City:MERCED
Mailing Address - State:CA
Mailing Address - Zip Code:95348-3121
Mailing Address - Country:US
Mailing Address - Phone:209-383-0989
Mailing Address - Fax:209-383-6836
Practice Address - Street 1:580 COLLINS DR
Practice Address - Street 2:
Practice Address - City:MERCED
Practice Address - State:CA
Practice Address - Zip Code:95348-3121
Practice Address - Country:US
Practice Address - Phone:209-383-0989
Practice Address - Fax:209-383-6836
Is Sole Proprietor?:No
Enumeration Date:2006-03-27
Last Update Date:2009-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG50711207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0087430Medicaid
CAGR0087430Medicaid
CAA51785Medicare UPIN