Provider Demographics
NPI:1205156965
Name:DAVID G. GROSS, D.O., P.C.
Entity type:Organization
Organization Name:DAVID G. GROSS, D.O., P.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:G
Authorized Official - Last Name:GROSS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:219-769-8989
Mailing Address - Street 1:6111 HARRISON ST
Mailing Address - Street 2:SUITE 120
Mailing Address - City:MERRILLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46410-2969
Mailing Address - Country:US
Mailing Address - Phone:219-980-6143
Mailing Address - Fax:219-980-6146
Practice Address - Street 1:6111 HARRISON ST
Practice Address - Street 2:SUITE 120
Practice Address - City:MERRILLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410-2969
Practice Address - Country:US
Practice Address - Phone:219-980-6143
Practice Address - Fax:219-980-6146
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-04
Last Update Date:2010-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN50004042A152W00000X, 207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000105018OtherANTHEM
IN100169420Medicaid
IN876880Medicare PIN
IN100169420Medicaid