Provider Demographics
NPI:1538193388
Name:GROSS, COLEMAN
Entity type:Individual
Prefix:
First Name:COLEMAN
Middle Name:
Last Name:GROSS
Suffix:
Gender:M
Credentials:
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 20106
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33622-0106
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:300 27TH ST
Practice Address - Street 2:STE 103
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94612-3124
Practice Address - Country:US
Practice Address - Phone:510-832-2663
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2008-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLG69240207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G692400Medicaid
P00364640OtherRAILROAD MEDICARE
CA00G692400OtherBLUE SHIELD
CA00G692400Medicaid
CA00G692404Medicare PIN
CA00G692403Medicare PIN