Provider Demographics
NPI:1770549180
Name:GROSS, JEFFREY L (MD)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:L
Last Name:GROSS
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 1:75 KINGS HIGHWAY CUTOFF
Mailing Address - Street 2:5TH FLOOR
Mailing Address - City:FAIRFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06824-5340
Mailing Address - Country:US
Mailing Address - Phone:203-333-1133
Mailing Address - Fax:
Practice Address - Street 1:75 KINGS HIGHWAY CUTOFF
Practice Address - Street 2:5TH FLOOR
Practice Address - City:FAIRFIELD
Practice Address - State:CT
Practice Address - Zip Code:06824-5340
Practice Address - Country:US
Practice Address - Phone:203-333-1133
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2008-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0254972084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001254978Medicaid
CT010025497CT01OtherANTHEM BLUE CROSS AND BLU
CT010025497CT01OtherANTHEM BLUE CROSS AND BLU
CT130012043Medicare PIN
CT001254978Medicaid