Provider Demographics
NPI:1598757395
Name:GROSMAN, MARK A (DC)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:A
Last Name:GROSMAN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1551 PROFESSIONAL LANE
Mailing Address - Street 2:#220
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80501
Mailing Address - Country:US
Mailing Address - Phone:303-772-9660
Mailing Address - Fax:303-772-9259
Practice Address - Street 1:1551 PROFESSIONAL LANE
Practice Address - Street 2:#220
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501
Practice Address - Country:US
Practice Address - Phone:303-772-9660
Practice Address - Fax:303-772-9259
Is Sole Proprietor?:No
Enumeration Date:2005-08-17
Last Update Date:2013-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC25141111N00000X
CO6729111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW18242Medicare ID - Type Unspecified
CAU68360Medicare UPIN