Provider Demographics
NPI:1912929043
Name:GROSS, EDWARD JOHN (MD)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:JOHN
Last Name:GROSS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:EDWARD
Other - Middle Name:JOHN
Other - Last Name:GROSS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1035 PRIMERA BLVD.
Mailing Address - Street 2:
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-2193
Mailing Address - Country:US
Mailing Address - Phone:407-333-3040
Mailing Address - Fax:407-333-3496
Practice Address - Street 1:1035 PRIMERA BLVD.
Practice Address - Street 2:
Practice Address - City:LAKE MARY
Practice Address - State:FL
Practice Address - Zip Code:32746-2193
Practice Address - Country:US
Practice Address - Phone:407-333-3040
Practice Address - Fax:407-333-3496
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2014-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0074351174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL2371491OtherAETNA
FL593613914OtherHUMANA
FL593613914OtherBEECH STREET
FL4856086004OtherCIGNA
FL1000573OtherUNITED HEALTHCARE
FL46407OtherBLUE CROSS/BLUE SHIELD
FLG11373Medicare UPIN
FL593613914OtherBEECH STREET