Provider Demographics
NPI:1679638415
Name:GROSS, LAURENCE (DPM)
Entity Type:Individual
Prefix:DR
First Name:LAURENCE
Middle Name:
Last Name:GROSS
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:167 MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:RIDGEFIELD PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07660
Mailing Address - Country:US
Mailing Address - Phone:201-440-0330
Mailing Address - Fax:201-440-2025
Practice Address - Street 1:167 MAIN STREET
Practice Address - Street 2:
Practice Address - City:RIDGEFIELD PARK
Practice Address - State:NJ
Practice Address - Zip Code:07660
Practice Address - Country:US
Practice Address - Phone:201-440-0330
Practice Address - Fax:201-440-2025
Is Sole Proprietor?:No
Enumeration Date:2006-12-22
Last Update Date:2008-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMD0001215213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0793809Medicaid
T45052Medicare UPIN
NJGR446866Medicare ID - Type Unspecified
NJ0793809Medicaid