Healthcare Provider Details

I. General information

NPI: 1720601669
Provider Name (Legal Business Name): MATTHEW GROSS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2020
Last Update Date: 09/17/2026
Certification Date: 09/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 N MEDICAL DR # E24
SALT LAKE CITY UT
84132-0001
US

IV. Provider business mailing address

30 N. MARIO CAPECCHI DR 3RD FLOOR SOUTH
SALT LAKE CITY UT
84112
US

V. Phone/Fax

Practice location:
  • Phone: 801-581-2772
  • Fax:
Mailing address:
  • Phone: 801-581-6709
  • Fax: 801-581-4343

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number14294740-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: