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General NPI Number Information
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NPI Number | 1871658278
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Entity Type | Organization
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Legal Business Name | KEITH MARK GROSS MD INC
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Dates
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Enumeration Date | 12/26/2006
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Last Update Date | 01/17/2008
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Provider Practice Location Address
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Address Line | 15247 11TH ST SUITE 400
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City | VICTORVILLE
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State | CA
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Zip | 92395-3727
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Country | US
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Telephone | 909-335-8638
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Fax | 909-335-8644
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Provider Business Mailing Address
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Address Line | PO BOX 51197 DEPT 1401
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City | LOS ANGELES
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State | CA
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Zip | 90051-5497
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | KEITH GROSS
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Credential | MD
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Telephone | 909-335-8638
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207N00000X
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Taxonomy Name | Dermatology Physician
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License Number | G63544
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License Number State | CA
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