Provider Demographics
NPI:1134370620
Name:JAY GROSS, M.D., A PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:JAY GROSS, M.D., A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:RACHEL
Authorized Official - Middle Name:
Authorized Official - Last Name:GRACIA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-496-3770
Mailing Address - Street 1:2222 SANTA MONICA BLVD
Mailing Address - Street 2:SUITE 107
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404-2304
Mailing Address - Country:US
Mailing Address - Phone:310-496-3770
Mailing Address - Fax:310-496-3767
Practice Address - Street 1:2222 SANTA MONICA BLVD
Practice Address - Street 2:SUITE 107
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-2304
Practice Address - Country:US
Practice Address - Phone:310-496-3770
Practice Address - Fax:310-496-3767
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-02
Last Update Date:2012-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG36307207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G373070Medicaid
CAA91767Medicare UPIN