Provider Demographics
NPI:1750321220
Name:GROSS, DHIMITRI ELICIA (MD)
Entity Type:Individual
Prefix:DR
First Name:DHIMITRI
Middle Name:ELICIA
Last Name:GROSS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7450 ALBERT RD
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:BRANDYWINE
Mailing Address - State:MD
Mailing Address - Zip Code:20613-3035
Mailing Address - Country:US
Mailing Address - Phone:301-888-2233
Mailing Address - Fax:301-888-9133
Practice Address - Street 1:7450 ALBERT RD
Practice Address - Street 2:2ND FLOOR
Practice Address - City:BRANDYWINE
Practice Address - State:MD
Practice Address - Zip Code:20613-3035
Practice Address - Country:US
Practice Address - Phone:301-888-2233
Practice Address - Fax:301-888-9133
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2014-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0055146207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD165759YVZMedicare PIN
MDG99409Medicare UPIN
MD165759ZDDBMedicare PIN
010426P45Medicare ID - Type Unspecified
MD165759YVZMedicare PIN
VA080191452OtherRAILROAD MEDICARE
VA005646014Medicaid