Provider Demographics
NPI:1750924528
Name:GROSS, DESARAE L
Entity type:Individual
Prefix:
First Name:DESARAE
Middle Name:L
Last Name:GROSS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:DESARAE
Other - Middle Name:L
Other - Last Name:LEWIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:138 W HIGHLAND RD STE 500
Mailing Address - Street 2:
Mailing Address - City:HOWELL
Mailing Address - State:MI
Mailing Address - Zip Code:48843-2168
Mailing Address - Country:US
Mailing Address - Phone:517-376-4831
Mailing Address - Fax:
Practice Address - Street 1:138 W HIGHLAND RD STE 500
Practice Address - Street 2:
Practice Address - City:HOWELL
Practice Address - State:MI
Practice Address - Zip Code:48843-2168
Practice Address - Country:US
Practice Address - Phone:517-376-4831
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-23
Last Update Date:2022-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156F00000XEye and Vision Services ProvidersTechnician/Technologist