Healthcare Provider Details

I. General information

NPI: 1457370736
Provider Name (Legal Business Name): MARK STEVEN GROSSMAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2006
Last Update Date: 06/24/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 MEDICAL PLAZA #365,530,420,120
LOS ANGELES CA
90095-3075
US

IV. Provider business mailing address

5767 W CENTURY BLVD SUITE 200
LOS ANGELES CA
90045-5632
US

V. Phone/Fax

Practice location:
  • Phone: 310-208-7777
  • Fax:
Mailing address:
  • Phone: 310-828-7172
  • Fax: 310-394-7807

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberG79624
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberG79624
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: