Provider Demographics
NPI:1881646602
Name:GROSS, EVAN (MD)
Entity Type:Individual
Prefix:DR
First Name:EVAN
Middle Name:
Last Name:GROSS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:EVAN
Other - Middle Name:
Other - Last Name:GROSS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:7981 GLADIOLUS DR
Mailing Address - Street 2:
Mailing Address - City:FT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33908-4154
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7981 GLADIOLUS DR
Practice Address - Street 2:
Practice Address - City:FT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33908-4154
Practice Address - Country:US
Practice Address - Phone:239-939-0999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2022-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME96840174400000X, 207RN0300X
MO2002018376174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLI64953Medicare UPIN
FL56558ZMedicare PIN