Provider Demographics
NPI:1639153786
Name:GROSS, ELLIOT (MD)
Entity Type:Individual
Prefix:DR
First Name:ELLIOT
Middle Name:
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 1:3831 HUGHES AVE.
Mailing Address - Street 2:#509
Mailing Address - City:CULVER CITY
Mailing Address - State:CA
Mailing Address - Zip Code:90232
Mailing Address - Country:US
Mailing Address - Phone:310-559-4833
Mailing Address - Fax:310-558-0624
Practice Address - Street 1:3831 HUGHES AVE
Practice Address - Street 2:#509
Practice Address - City:CULVER CITY
Practice Address - State:CA
Practice Address - Zip Code:90232-2751
Practice Address - Country:US
Practice Address - Phone:310-559-4833
Practice Address - Fax:310-558-0624
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-02
Last Update Date:2010-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG28678174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0418740001Medicare NSC
CAA43819Medicare UPIN
CAG28678Medicare PIN
CADE548ZMedicare PIN