Provider Demographics
NPI:1144286832
Name:GROSSO, PETER CHARLES (MD)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:CHARLES
Last Name:GROSSO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1005 COMMERCIAL LANE
Mailing Address - Street 2:GODWIN BLDG ON RT 10, SUITE 220
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23434-8149
Mailing Address - Country:US
Mailing Address - Phone:757-668-2600
Mailing Address - Fax:757-668-2620
Practice Address - Street 1:1005 COMMERCIAL LANE
Practice Address - Street 2:GODWIN BLDG ON RT 10, SUITE 220
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23434-8149
Practice Address - Country:US
Practice Address - Phone:757-668-2600
Practice Address - Fax:757-668-2620
Is Sole Proprietor?:No
Enumeration Date:2006-04-22
Last Update Date:2012-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101042222208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC890583WMedicaid
VA6746209Medicaid
F50924Medicare UPIN
VA6746209Medicaid