Healthcare Provider Details

I. General information

NPI: 1346225828
Provider Name (Legal Business Name): DAVID J GROSS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/07/2005
Last Update Date: 08/29/2024
Certification Date: 08/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 S PONCE DE LEON BLVD STE 3B
ST AUGUSTINE FL
32084-6013
US

IV. Provider business mailing address

18228 N US HIGHWAY 41
LUTZ FL
33549-4400
US

V. Phone/Fax

Practice location:
  • Phone: 813-321-1786
  • Fax: 813-321-1787
Mailing address:
  • Phone: 813-321-1786
  • Fax: 813-321-1787

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberME62729
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: