1740484187 NPI number — STEWART CORY GROSS M.D.

Table of content: DR. WAYNE W HOEFT O.D. (NPI 1801851571)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740484187 NPI number — STEWART CORY GROSS M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GROSS
Provider First Name:
STEWART
Provider Middle Name:
CORY
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1740484187
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/14/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2660 MAIN ST STE 311
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BRIDGEPORT
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06606-5301
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
203-367-4008
Provider Business Mailing Address Fax Number:
203-368-0292

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2660 MAIN ST STE 311
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BRIDGEPORT
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06606-5301
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-367-4008
Provider Business Practice Location Address Fax Number:
203-368-0292
Provider Enumeration Date:
06/11/2007

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: 2086S0105X , with the licence number:  29910 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207XS0106X , with the licence number: 029910 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: ZS224 . This is a "OXFORD" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 001125 . This is a "HEALTHNET" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 001299107 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 010029910CT01 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 4351331 . This is a "AETNA US HEALTH CARE" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".




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