Provider Demographics
NPI:1578660908
Name:GROSS, STEVEN PAUL (MD)
Entity Type:Individual
Prefix:
First Name:STEVEN
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:PO BOX 187
Mailing Address - Street 2:
Mailing Address - City:DULCE
Mailing Address - State:NM
Mailing Address - Zip Code:87528-0187
Mailing Address - Country:US
Mailing Address - Phone:575-759-7232
Mailing Address - Fax:575-759-7294
Practice Address - Street 1:12000 STONE LAKE ROAD
Practice Address - Street 2:
Practice Address - City:DULCE
Practice Address - State:NM
Practice Address - Zip Code:87528
Practice Address - Country:US
Practice Address - Phone:575-759-7232
Practice Address - Fax:575-759-7294
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2010-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM84-44207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM8HL709OtherMEDICARE PROVIDER #
NMHSZ196OtherMEDICARE PART B
NM00032607Medicaid
NMK3526Medicaid
NME46822Medicare UPIN
NM00032607Medicaid