Provider Demographics
NPI:1144511627
Name:GROSS, MARK DAVID (LAC, MSTOM)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:DAVID
Last Name:GROSS
Suffix:
Gender:M
Credentials:LAC, MSTOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:138 MAPLE ST
Mailing Address - Street 2:APT 2
Mailing Address - City:CROTON ON HUDSON
Mailing Address - State:NY
Mailing Address - Zip Code:10520-2322
Mailing Address - Country:US
Mailing Address - Phone:212-444-8710
Mailing Address - Fax:
Practice Address - Street 1:928 BROADWAY
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10010-6008
Practice Address - Country:US
Practice Address - Phone:212-444-8710
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-02
Last Update Date:2011-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003800-01171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist