Healthcare Provider Details

I. General information

NPI: 1750321220
Provider Name (Legal Business Name): DHIMITRI ELICIA GROSS M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2006
Last Update Date: 12/19/2025
Certification Date: 12/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23000 MOAKLEY ST
LEONARDTOWN MD
20650-2915
US

IV. Provider business mailing address

1400 WEWATTA ST STE 350
DENVER CO
80202-5553
US

V. Phone/Fax

Practice location:
  • Phone: 240-744-1100
  • Fax: 855-592-2119
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberC4011
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberD0055146
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD490238C
License Number StatePA
# 4
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0101222399
License Number StateVA
# 5
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number13585-320
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: