Provider Demographics
NPI:1447592498
Name:GROSSETETE, MARK LAND (MD, PHD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:LAND
Last Name:GROSSETETE
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 CAMINO DE VIDA STE 300
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:NM
Mailing Address - Zip Code:88435-2267
Mailing Address - Country:US
Mailing Address - Phone:575-472-4311
Mailing Address - Fax:
Practice Address - Street 1:117 CAMINO DE VIDA STE 300
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:NM
Practice Address - Zip Code:88435
Practice Address - Country:US
Practice Address - Phone:575-472-4311
Practice Address - Fax:575-472-4313
Is Sole Proprietor?:No
Enumeration Date:2013-03-17
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2017-0779207L00000X, 207LA0401X, 207R00000X, 208VP0000X, 2084N0400X
NM390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207LA0401XAllopathic & Osteopathic PhysiciansAnesthesiologyAddiction Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program