Provider Demographics
NPI:1043299639
Name:GROSS, GARY PAUL (MD)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:PAUL
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 1:1802 BRAEBURN DRIVE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:VA
Mailing Address - Zip Code:24153-7357
Mailing Address - Country:US
Mailing Address - Phone:540-772-3421
Mailing Address - Fax:540-772-5994
Practice Address - Street 1:1802 BRAEBURN DR
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:VA
Practice Address - Zip Code:24153-7357
Practice Address - Country:US
Practice Address - Phone:540-772-3421
Practice Address - Fax:540-772-5994
Is Sole Proprietor?:No
Enumeration Date:2006-01-11
Last Update Date:2010-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101029581207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA005900816Medicaid
VAP00276914OtherMEDICARE RAILROAD
VA005900816Medicaid
VA00W697L23Medicare ID - Type UnspecifiedRICHMOND MEDICARE