Provider Demographics
NPI:1750321220
Name:GROSS, DHIMITRI ELICIA (MD)
Entity type:Individual
Prefix:DR
First Name:DHIMITRI
Middle Name:ELICIA
Last Name:GROSS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7259 S BINGHAM JUNCTION BLVD
Mailing Address - Street 2:
Mailing Address - City:MIDVALE
Mailing Address - State:UT
Mailing Address - Zip Code:84047-4860
Mailing Address - Country:US
Mailing Address - Phone:800-453-3030
Mailing Address - Fax:
Practice Address - Street 1:329 FLOYD DR
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:KY
Practice Address - Zip Code:41008-8261
Practice Address - Country:US
Practice Address - Phone:502-732-1082
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2025-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD490238C207Q00000X
KYC4011207Q00000X
WI13585-320207Q00000X
VA0101222399207Q00000X
MDD0055146207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD165759YVZMedicare PIN
MDG99409Medicare UPIN
MD165759ZDDBMedicare PIN
010426P45Medicare ID - Type Unspecified
MD165759YVZMedicare PIN
VA080191452OtherRAILROAD MEDICARE
VA005646014Medicaid