Provider Demographics
NPI:1356454128
Name:GROSS, MICHAEL PAUL (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:PAUL
Last Name:GROSS
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 1:22144 CLARENDON ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:WOODLAND HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91367-6324
Mailing Address - Country:US
Mailing Address - Phone:818-999-1144
Mailing Address - Fax:818-226-5980
Practice Address - Street 1:22144 CLARENDON ST
Practice Address - Street 2:SUITE 201
Practice Address - City:WOODLAND HILLS
Practice Address - State:CA
Practice Address - Zip Code:91367-6324
Practice Address - Country:US
Practice Address - Phone:818-999-1144
Practice Address - Fax:818-226-5980
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC304252084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAC30425OtherLICENSE