Provider Demographics
NPI:1992815773
Name:GROSSBARD, HOWARD ALAN (M D)
Entity type:Individual
Prefix:
First Name:HOWARD
Middle Name:ALAN
Last Name:GROSSBARD
Suffix:
Gender:M
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:825 VENETIAN PKWY
Mailing Address - Street 2:SUITE B
Mailing Address - City:VENICE
Mailing Address - State:FL
Mailing Address - Zip Code:34285-7163
Mailing Address - Country:US
Mailing Address - Phone:941-484-3089
Mailing Address - Fax:941-484-3263
Practice Address - Street 1:1041 RIDGEWOOD AVE
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:FL
Practice Address - Zip Code:34285-6978
Practice Address - Country:US
Practice Address - Phone:941-484-6353
Practice Address - Fax:941-484-6608
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2015-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL31798207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL372381000Medicaid
FL372381000Medicaid
58286Medicare ID - Type Unspecified