Provider Demographics
NPI:1952496473
Name:GROSS, BENNETT RAYMOND (MD)
Entity Type:Individual
Prefix:
First Name:BENNETT
Middle Name:RAYMOND
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 1:2600 VIA DE LA VALLE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:DEL MAR
Mailing Address - State:CA
Mailing Address - Zip Code:92014-1992
Mailing Address - Country:US
Mailing Address - Phone:858-499-2600
Mailing Address - Fax:
Practice Address - Street 1:12710 CARMEL COUNTRY RD
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92130-2153
Practice Address - Country:US
Practice Address - Phone:858-499-2600
Practice Address - Fax:619-526-6093
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2014-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD25167207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine