Provider Demographics
NPI:1487679445
Name:GROSSMAN, GARY J (MD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:J
Last Name:GROSSMAN
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 1:201 N BUFFALO DR
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89145-0373
Mailing Address - Country:US
Mailing Address - Phone:702-242-2737
Mailing Address - Fax:702-255-3170
Practice Address - Street 1:201 N BUFFALO DR
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89145-0373
Practice Address - Country:US
Practice Address - Phone:702-242-2737
Practice Address - Fax:702-255-3170
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2023-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV6261207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV2019119Medicaid
NVWCMAV04Medicare ID - Type Unspecified
NV2019119Medicaid