Provider Demographics
NPI:1750335527
Name:GROSSMAN, STANLEY J (MD)
Entity type:Individual
Prefix:
First Name:STANLEY
Middle Name:J
Last Name:GROSSMAN
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 1:712 N WASHINGTON AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75246-1619
Mailing Address - Country:US
Mailing Address - Phone:214-826-8822
Mailing Address - Fax:214-826-9792
Practice Address - Street 1:3500 GASTON AVE
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75246
Practice Address - Country:US
Practice Address - Phone:214-826-8822
Practice Address - Fax:214-826-9792
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2012-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK0791207U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207U00000XAllopathic & Osteopathic PhysiciansNuclear Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX129567707Medicaid
TX129567706Medicaid
TX129567709Medicaid
TX129567709Medicaid
TX8085B9Medicare PIN
TX300135543Medicare PIN
TX129567707Medicaid
TXP00034776Medicare PIN