Healthcare Provider Details

I. General information

NPI: 1396827358
Provider Name (Legal Business Name): ROBERT GROSS DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/19/2006
Last Update Date: 06/30/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6425 LYNCH CANYON DR
LAKE ISABELLA CA
93240-9726
US

IV. Provider business mailing address

6425 LYNCH CANYON DR
LAKE ISABELLA CA
93240-9726
US

V. Phone/Fax

Practice location:
  • Phone: 760-379-8630
  • Fax:
Mailing address:
  • Phone: 760-379-8630
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number20A7951
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: