Healthcare Provider Details

I. General information

NPI: 1194791293
Provider Name (Legal Business Name): BERNARD JOSEPH GROS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/27/2006
Last Update Date: 01/07/2020
Certification Date: 01/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3400 QUADRANGLE BLVD
ORLANDO FL
32817-1492
US

IV. Provider business mailing address

3400 QUADRANGLE BLVD
ORLANDO FL
32817-1492
US

V. Phone/Fax

Practice location:
  • Phone: 407-266-3627
  • Fax: 407-882-4799
Mailing address:
  • Phone: 407-266-3627
  • Fax: 407-882-4799

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207U00000X
TaxonomyNuclear Medicine Physician
License NumberME0073065
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberME0073065
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: