Provider Demographics
NPI:1447208194
Name:DAVID M. GROSSMAN, M.D., MEDICAL CORPORATION
Entity type:Organization
Organization Name:DAVID M. GROSSMAN, M.D., MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:M
Authorized Official - Last Name:GROSSMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-528-1290
Mailing Address - Street 1:5525 ETIWANDA AVE.
Mailing Address - Street 2:SUITE 200
Mailing Address - City:TARZANA
Mailing Address - State:CA
Mailing Address - Zip Code:91356-6131
Mailing Address - Country:US
Mailing Address - Phone:818-528-1290
Mailing Address - Fax:818-528-1295
Practice Address - Street 1:18375 VENTURA BLVD
Practice Address - Street 2:SUITE 640
Practice Address - City:TARZANA
Practice Address - State:CA
Practice Address - Zip Code:91356-4218
Practice Address - Country:US
Practice Address - Phone:818-908-8048
Practice Address - Fax:818-908-8072
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-05
Last Update Date:2016-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA52722207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A527220OtherBLUE SHIELD
CAG01148Medicare UPIN
CA00A527220OtherBLUE SHIELD
CAG01148Medicare UPIN