Provider Demographics
NPI:1831112317
Name:GROSS, STEPHEN M (OD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:M
Last Name:GROSS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10184 EASTERN SHORE BLVD
Mailing Address - Street 2:STE A
Mailing Address - City:SPANISH FORT
Mailing Address - State:AL
Mailing Address - Zip Code:36527-5814
Mailing Address - Country:US
Mailing Address - Phone:251-368-8767
Mailing Address - Fax:251-368-4565
Practice Address - Street 1:166 LINDBERG AVE
Practice Address - Street 2:
Practice Address - City:ATMORE
Practice Address - State:AL
Practice Address - Zip Code:36502-3206
Practice Address - Country:US
Practice Address - Phone:251-368-8767
Practice Address - Fax:251-368-4565
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2020-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALS486TA041152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL529503380Medicaid
AL529503380Medicaid
AL000059651Medicare ID - Type UnspecifiedPROVIDER NUMBER
AL0129860001Medicare NSC
AL0129860002Medicare NSC