Provider Demographics
NPI:1730171786
Name:GROSSBARD, LEE JAY (MD)
Entity type:Individual
Prefix:DR
First Name:LEE
Middle Name:JAY
Last Name:GROSSBARD
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 1:13933 17TH ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:DADE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:33525-4604
Mailing Address - Country:US
Mailing Address - Phone:352-437-5971
Mailing Address - Fax:
Practice Address - Street 1:13933 17TH ST
Practice Address - Street 2:SUITE 200
Practice Address - City:DADE CITY
Practice Address - State:FL
Practice Address - Zip Code:33525-4604
Practice Address - Country:US
Practice Address - Phone:352-437-5971
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-16
Last Update Date:2015-07-28
Deactivation Date:2006-03-23
Deactivation Code:
Reactivation Date:2006-03-29
Provider Licenses
StateLicense IDTaxonomies
FLME44251208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL203003OtherAMERIGROUP
FL51224OtherBLUE CROSS BLUE SHIELD FL
FL3705092OtherUNITED HEALTHCARE
FL020018581OtherMEDICARE RAILROAD
FL00639OtherWELLCARE
FL0623994OtherAETNA HEALTHCARE
FL200072OtherAVMED
FL00639OtherWELLCARE
FL200072OtherAVMED