Provider Demographics
NPI:1356348528
Name:GROSS, JONATHON LOBER (MD)
Entity type:Individual
Prefix:
First Name:JONATHON
Middle Name:LOBER
Last Name:GROSS
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:PO BOX 35448
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85740-5448
Mailing Address - Country:US
Mailing Address - Phone:520-529-2940
Mailing Address - Fax:520-229-1207
Practice Address - Street 1:7440 N ORACLE RD
Practice Address - Street 2:NO. 4
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85704-6385
Practice Address - Country:US
Practice Address - Phone:520-529-2940
Practice Address - Fax:520-229-1207
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-03
Last Update Date:2013-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ28061207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
20-2264724OtherFEDERAL TAX ID NUMBER
AZZ101771Medicare PIN
AZAZ05733Medicare ID - Type UnspecifiedELECTRONIC SUBMITTER ID
AZZ101772Medicare PIN
20-2264724OtherFEDERAL TAX ID NUMBER