Provider Demographics
NPI:1942220926
Name:GROSSMAN, STEPHEN MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:MICHAEL
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 1:87 E OLIVE AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93728-3059
Mailing Address - Country:US
Mailing Address - Phone:559-499-1233
Mailing Address - Fax:559-499-1232
Practice Address - Street 1:87 E OLIVE AVE STE 100
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93728-3059
Practice Address - Country:US
Practice Address - Phone:559-499-1233
Practice Address - Fax:559-499-1232
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-20
Last Update Date:2011-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG64749207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G647490Medicaid
CAE03369Medicare UPIN
CA00G647491Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER