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General NPI Number Information
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NPI Number | 1184629271
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Entity Type | Individual
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Provider Name | FREDRIC JAY GROSS M.D.
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Gender | Male
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Dates
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Enumeration Date | 06/16/2005
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Last Update Date | 02/02/2021
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Provider Practice Location Address
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Address Line | 109 WIMBLEDON SQ STE E
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City | CHESAPEAKE
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State | VA
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Zip | 23320-4945
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Country | US
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Telephone | 757-547-9830
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Fax | 757-548-0721
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Provider Business Mailing Address
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Address Line | PO BOX 1290
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City | FOREST
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State | VA
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Zip | 24551-1290
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Country | US
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Telephone | 434-385-5600
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207W00000X
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Taxonomy Name | Ophthalmology Physician
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License Number | 0101046621
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License Number State | VA
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