Provider Demographics
NPI:1851359731
Name:GROSSMAN, BRUCE MARK (MD)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:MARK
Last Name:GROSSMAN
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 1:1000 36TH ST
Mailing Address - Street 2:
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32960-4862
Mailing Address - Country:US
Mailing Address - Phone:772-299-3511
Mailing Address - Fax:772-299-3517
Practice Address - Street 1:3450 11TH COURT
Practice Address - Street 2:SUITE 206
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32960-5012
Practice Address - Country:US
Practice Address - Phone:772-299-3511
Practice Address - Fax:772-299-3517
Is Sole Proprietor?:No
Enumeration Date:2006-05-02
Last Update Date:2016-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL53017207RG0100X
CO45365207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL049666900Medicaid
FL049666900Medicaid
FL07622Medicare PIN
FL07622Medicare PIN
COAG3210755OtherDEA
FLB63511Medicare UPIN