Healthcare Provider Details

I. General information

NPI: 1942369210
Provider Name (Legal Business Name): GARY ALAN KROSIN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/06/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2912 SW TRAILSIDE PATH
STUART FL
34997-9013
US

IV. Provider business mailing address

2912 SW TRAILSIDE PATH
STUART FL
34997-9012
US

V. Phone/Fax

Practice location:
  • Phone: 772-285-7799
  • Fax: 772-264-4602
Mailing address:
  • Phone: 772-285-7799
  • Fax: 772-264-4602

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085B0100X
TaxonomyBody Imaging Physician
License Number37516
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: