Healthcare Provider Details

I. General information

NPI: 1104865898
Provider Name (Legal Business Name): KENNETH GARY GROSS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2006
Last Update Date: 05/05/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5222 BALBOA AVE SIXTH FLOOR
SAN DIEGO CA
92117-6904
US

IV. Provider business mailing address

5222 BALBOA AVE SIXTH FLOOR
SAN DIEGO CA
92117-6904
US

V. Phone/Fax

Practice location:
  • Phone: 858-292-5101
  • Fax: 858-292-0514
Mailing address:
  • Phone: 858-292-5101
  • Fax: 858-292-0514

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberA37440
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License NumberA37440
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License NumberA37440
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: