Provider Demographics
NPI:1124053665
Name:GROSS, BENJAMIN (MD)
Entity type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:
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 1:6221 WILSHIRE BLVD
Mailing Address - Street 2:SUITE 509
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90048-5201
Mailing Address - Country:US
Mailing Address - Phone:323-939-1689
Mailing Address - Fax:323-939-7084
Practice Address - Street 1:6221 WILSHIRE BLVD
Practice Address - Street 2:SUITE 509
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90048-5201
Practice Address - Country:US
Practice Address - Phone:323-939-1689
Practice Address - Fax:323-939-7084
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG417772084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA48689Medicare UPIN