Provider Demographics
NPI:1649380668
Name:GROSE, ANDREW JOHN (MD)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:JOHN
Last Name:GROSE
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 1:21145 BANK MILL RD
Mailing Address - Street 2:
Mailing Address - City:SARATOGA
Mailing Address - State:CA
Mailing Address - Zip Code:95070-5706
Mailing Address - Country:US
Mailing Address - Phone:408-823-2476
Mailing Address - Fax:
Practice Address - Street 1:21145 BANK MILL RD
Practice Address - Street 2:
Practice Address - City:SARATOGA
Practice Address - State:CA
Practice Address - Zip Code:95070-5706
Practice Address - Country:US
Practice Address - Phone:408-823-2476
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2021-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG17977207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G179770Medicaid
CAA40239Medicare UPIN
CA00G179770Medicare ID - Type Unspecified