Provider Demographics
NPI:1699768283
Name:GROSNER, GARY (MD)
Entity type:Individual
Prefix:MR
First Name:GARY
Middle Name:
Last Name:GROSNER
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 1:100 HIGH ST
Mailing Address - Street 2:C3
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14203-1126
Mailing Address - Country:US
Mailing Address - Phone:716-859-2243
Mailing Address - Fax:716-859-2885
Practice Address - Street 1:100 HIGH ST
Practice Address - Street 2:C3
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14203-1126
Practice Address - Country:US
Practice Address - Phone:716-859-2243
Practice Address - Fax:716-859-2885
Is Sole Proprietor?:No
Enumeration Date:2005-08-29
Last Update Date:2015-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1657211174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01348136Medicaid
NYJ400070089Medicare PIN
NY01348136Medicaid