Healthcare Provider Details

I. General information

NPI: 1578660908
Provider Name (Legal Business Name): STEVEN PAUL GROSS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 09/24/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12000 STONE LAKE ROAD
DULCE NM
87528
US

IV. Provider business mailing address

PO BOX 187
DULCE NM
87528-0187
US

V. Phone/Fax

Practice location:
  • Phone: 575-759-7232
  • Fax: 575-759-7294
Mailing address:
  • Phone: 575-759-7232
  • Fax: 575-759-7294

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number84-44
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: