Provider Demographics
NPI:1306828322
Name:GROSSMAN, REX DANIEL (MD)
Entity Type:Individual
Prefix:DR
First Name:REX
Middle Name:DANIEL
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 1:1011 W 2ND ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47403-2216
Mailing Address - Country:US
Mailing Address - Phone:812-334-1213
Mailing Address - Fax:812-333-5039
Practice Address - Street 1:1011 W 2ND ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47403-2216
Practice Address - Country:US
Practice Address - Phone:812-334-1213
Practice Address - Fax:812-333-5039
Is Sole Proprietor?:No
Enumeration Date:2005-11-16
Last Update Date:2012-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ININ01027063A207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100358360AMedicaid
IN549340AMedicare ID - Type Unspecified
IND69753Medicare UPIN