Healthcare Provider Details

I. General information

NPI: 1750355392
Provider Name (Legal Business Name): DAVID JON GROSSKLAUS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/13/2006
Last Update Date: 08/08/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6007 E BASELINE RD SUITE 105
MESA AZ
85206-4801
US

IV. Provider business mailing address

6007 E BASELINE RD SUITE 105
MESA AZ
85206-4815
US

V. Phone/Fax

Practice location:
  • Phone: 480-897-2727
  • Fax: 480-892-3035
Mailing address:
  • Phone: 480-897-2727
  • Fax: 480-892-3035

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number25961
License Number StateAZ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: