Provider Demographics
NPI:1740276351
Name:GROSS, CHARLES (DPM)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:
Last Name:GROSS
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:111 HIGH RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06905-3813
Mailing Address - Country:US
Mailing Address - Phone:203-322-4199
Mailing Address - Fax:203-329-8017
Practice Address - Street 1:111 HIGH RIDGE RD
Practice Address - Street 2:
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06905-3813
Practice Address - Country:US
Practice Address - Phone:203-322-4199
Practice Address - Fax:203-329-8017
Is Sole Proprietor?:No
Enumeration Date:2005-09-20
Last Update Date:2009-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT482213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT0212695002OtherCIGNA
CT607508OtherCONNECTICARE
CTP383730OtherOXFORD
CT030000482CT01OtherBLUE CROSS/BLUE SHIELD
CT3V1076OtherHEALTHNET
CT004099017Medicaid
CT27-00926OtherEVERCARE
CT0212695002OtherCIGNA
CT6136930001Medicare NSC
CT480000415Medicare ID - Type Unspecified