Provider Demographics
NPI:1275574253
Name:GROSSMAN, JAY R (MD)
Entity Type:Individual
Prefix:DR
First Name:JAY
Middle Name:R
Last Name:GROSSMAN
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 1:3629 VISTA WAY
Mailing Address - Street 2:
Mailing Address - City:OCEANSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92056-4522
Mailing Address - Country:US
Mailing Address - Phone:760-828-9200
Mailing Address - Fax:760-828-9141
Practice Address - Street 1:3629 VISTA WAY
Practice Address - Street 2:
Practice Address - City:OCEANSIDE
Practice Address - State:CA
Practice Address - Zip Code:92056-4522
Practice Address - Country:US
Practice Address - Phone:760-828-9200
Practice Address - Fax:760-828-9141
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2008-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG27789207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA070003595OtherRAILROAD MEDICARE
CA070003595OtherRAILROAD MEDICARE
CAA91081Medicare UPIN
CAWG27789DMedicare PIN
CA00G277890Medicare UPIN
CAWG27789BMedicare PIN