Provider Demographics
NPI:1053386763
Name:GROSS, ERIC M (MD)
Entity type:Individual
Prefix:
First Name:ERIC
Middle Name:M
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 1:2400 TRAWOOD DR STE 304
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79936-4122
Mailing Address - Country:US
Mailing Address - Phone:915-591-8400
Mailing Address - Fax:915-591-8401
Practice Address - Street 1:2400 TRAWOOD DR STE 304
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79936-4122
Practice Address - Country:US
Practice Address - Phone:915-591-8400
Practice Address - Fax:915-591-8401
Is Sole Proprietor?:No
Enumeration Date:2006-02-17
Last Update Date:2024-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN2537207YX0905X
SD6053207YS0123X
CAA60281207YS0123X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YX0905XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngology/Facial Plastic Surgery
No207YS0123XAllopathic & Osteopathic PhysiciansOtolaryngologyFacial Plastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD6053OtherDAKOTACARE
SDP00439542OtherRR MEDICARE
SD6520500Medicaid
SD4993122OtherWELLMARK
CA00A602811Medicare ID - Type Unspecified
CAH71742Medicare UPIN
SDP00439542OtherRR MEDICARE
SD6520500Medicaid