Provider Demographics
NPI:1275507154
Name:GROSSMAN, GARY DAVID (MD)
Entity Type:Individual
Prefix:MR
First Name:GARY
Middle Name:DAVID
Last Name:GROSSMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:85 CIVIC CENTER PLZ
Mailing Address - Street 2:104
Mailing Address - City:POUGHKEEPSIE
Mailing Address - State:NY
Mailing Address - Zip Code:12601-2498
Mailing Address - Country:US
Mailing Address - Phone:845-471-5519
Mailing Address - Fax:845-471-2928
Practice Address - Street 1:241 NORTH RD
Practice Address - Street 2:
Practice Address - City:POUGHKEEPSIE
Practice Address - State:NY
Practice Address - Zip Code:12601-1154
Practice Address - Country:US
Practice Address - Phone:845-471-5519
Practice Address - Fax:845-471-2928
Is Sole Proprietor?:No
Enumeration Date:2006-02-15
Last Update Date:2012-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1865032085R0202X, 2085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01646491Medicaid
G25608Medicare UPIN
NY626421Medicare ID - Type Unspecified
NY6264232722Medicare PIN
NY62642EN841Medicare PIN
NY01646491Medicaid