Provider Demographics
NPI:1457501934
Name:DAVID J GROSS MD PA
Entity Type:Organization
Organization Name:DAVID J GROSS MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:J
Authorized Official - Last Name:GROSS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:904-823-9992
Mailing Address - Street 1:1100-3 S PONCE DE LEON BLVD
Mailing Address - Street 2:SUITE 3B
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32084-6013
Mailing Address - Country:US
Mailing Address - Phone:904-823-9992
Mailing Address - Fax:
Practice Address - Street 1:1100-3 S PONCE DE LEON BLVD
Practice Address - Street 2:SUITE 3B
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32084-6013
Practice Address - Country:US
Practice Address - Phone:904-823-9992
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-22
Last Update Date:2008-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty