Provider Demographics
NPI:1881676542
Name:GROSSMAN, GARY STUART (DC)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:STUART
Last Name:GROSSMAN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 N KIRKMAN RD
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32811-1404
Mailing Address - Country:US
Mailing Address - Phone:407-291-1000
Mailing Address - Fax:407-291-2538
Practice Address - Street 1:110 N KIRKMAN RD
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32811-1404
Practice Address - Country:US
Practice Address - Phone:407-291-1000
Practice Address - Fax:407-291-2538
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-17
Last Update Date:2011-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH4743111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL381365700Medicaid
FL381365700Medicaid
FL22011Medicare ID - Type Unspecified