Provider Demographics
NPI:1336143247
Name:GROSS, GARY LANCE (MD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:LANCE
Last Name:GROSS
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:DEPT. 453 PO BOX 1000
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38148-0001
Mailing Address - Country:US
Mailing Address - Phone:828-575-2625
Mailing Address - Fax:828-350-2174
Practice Address - Street 1:802 W PARK AVE
Practice Address - Street 2:STE 213
Practice Address - City:OCEAN
Practice Address - State:NJ
Practice Address - Zip Code:07712-8526
Practice Address - Country:US
Practice Address - Phone:732-695-2555
Practice Address - Fax:732-695-2552
Is Sole Proprietor?:No
Enumeration Date:2005-06-08
Last Update Date:2023-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA04805600207K00000X
NJMA048056207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ3408400Medicaid
NJ029133ZKRPOtherMEDICARE PTAN
NJ029133ZVF5OtherMEDICARE PTAN