1144286832 NPI number — PETER CHARLES GROSSO MD

Table of content: DR. SANDRA M JUSTINIANO D.M.D. (NPI 1295849875)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144286832 NPI number — PETER CHARLES GROSSO MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GROSSO
Provider First Name:
PETER
Provider Middle Name:
CHARLES
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1144286832
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/10/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1005 COMMERCIAL LANE
Provider Second Line Business Mailing Address:
GODWIN BLDG ON RT 10, SUITE 220
Provider Business Mailing Address City Name:
SUFFOLK
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23434-8149
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
757-668-2600
Provider Business Mailing Address Fax Number:
757-668-2620

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1005 COMMERCIAL LANE
Provider Second Line Business Practice Location Address:
GODWIN BLDG ON RT 10, SUITE 220
Provider Business Practice Location Address City Name:
SUFFOLK
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23434-8149
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
757-668-2600
Provider Business Practice Location Address Fax Number:
757-668-2620
Provider Enumeration Date:
04/22/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  0101042222 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 890583W , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 6746209 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".