Provider Demographics
NPI:1932105285
Name:GROSS, MICHAEL LESLIE (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:LESLIE
Last Name:GROSS
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 1:828 HEALTHY WAY
Mailing Address - Street 2:SUITE 300
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23462-7958
Mailing Address - Country:US
Mailing Address - Phone:757-965-6165
Mailing Address - Fax:757-965-6296
Practice Address - Street 1:828 HEALTHY WAY
Practice Address - Street 2:SUITE 300
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23462-7958
Practice Address - Country:US
Practice Address - Phone:757-965-6165
Practice Address - Fax:757-965-6296
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-22
Last Update Date:2012-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101052313207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA5900379Medicaid
VA77060OtherOPTIMA
VA075428OtherANTHEM BC/BS
NC890625AOtherNC MEDICAID
VA070008396OtherRR MEDICARE
VA070008396OtherRR MEDICARE
VA5900379Medicaid