Provider Demographics
NPI:1750355392
Name:GROSSKLAUS, DAVID JON (MD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:JON
Last Name:GROSSKLAUS
Suffix:
Gender:M
Credentials:MD
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Other - Credentials:
Mailing Address - Street 1:6007 E BASELINE RD
Mailing Address - Street 2:SUITE 105
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85206-4815
Mailing Address - Country:US
Mailing Address - Phone:480-897-2727
Mailing Address - Fax:480-892-3035
Practice Address - Street 1:6007 E BASELINE RD
Practice Address - Street 2:SUITE 105
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206-4801
Practice Address - Country:US
Practice Address - Phone:480-897-2727
Practice Address - Fax:480-892-3035
Is Sole Proprietor?:No
Enumeration Date:2006-02-13
Last Update Date:2013-08-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
AZ25961208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZH52890Medicare UPIN
103474Medicare ID - Type Unspecified