Provider Demographics
NPI:1134149628
Name:GROSS, JERRY LEE (DPM)
Entity type:Individual
Prefix:DR
First Name:JERRY
Middle Name:LEE
Last Name:GROSS
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:247 SHILOH RD
Mailing Address - Street 2:
Mailing Address - City:FOREST CITY
Mailing Address - State:NC
Mailing Address - Zip Code:28043-6958
Mailing Address - Country:US
Mailing Address - Phone:828-245-6405
Mailing Address - Fax:828-245-3923
Practice Address - Street 1:247 SHILOH RD
Practice Address - Street 2:
Practice Address - City:FOREST CITY
Practice Address - State:NC
Practice Address - Zip Code:28043-6958
Practice Address - Country:US
Practice Address - Phone:828-245-6405
Practice Address - Fax:828-245-3923
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2008-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC422213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC790800JMedicaid
NC2433291CMedicare ID - Type Unspecified
NCU72597Medicare UPIN
NC3901550001Medicare NSC