Provider Demographics
NPI:1245204403
Name:GROSS, ROBERT B (OD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:B
Last Name:GROSS
Suffix:
Gender:M
Credentials:OD
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 425789
Mailing Address - Street 2:MEDICAL E23-2S
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02142-0015
Mailing Address - Country:US
Mailing Address - Phone:617-253-4351
Mailing Address - Fax:
Practice Address - Street 1:77 MASS AVE
Practice Address - Street 2:MEDICAL E23-2S
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02139-4301
Practice Address - Country:US
Practice Address - Phone:617-253-4351
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-15
Last Update Date:2012-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2913152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAW16397OtherBLUE CROSS
T92630Medicare UPIN
MA430958Medicare ID - Type Unspecified