Provider Demographics
NPI:1952357188
Name:GROSS, KEITH MARK (MD)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:MARK
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:PO BOX 848950
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90084-8950
Mailing Address - Country:US
Mailing Address - Phone:909-335-8638
Mailing Address - Fax:909-335-8644
Practice Address - Street 1:12550 HESPERIA RD
Practice Address - Street 2:400
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92395
Practice Address - Country:US
Practice Address - Phone:909-335-8638
Practice Address - Fax:909-335-8644
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-26
Last Update Date:2018-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV7006207N00000X
CAG63544207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG635440Medicare ID - Type Unspecified
CAG635444Medicare ID - Type Unspecified
NVV32038Medicare ID - Type Unspecified
F17121Medicare UPIN
CAG635448Medicare ID - Type Unspecified
CAG635442Medicare ID - Type Unspecified
CAG635449Medicare ID - Type Unspecified