Provider Demographics
NPI:1265460877
Name:GROVES, MACK JAY IV (DPM)
Entity Type:Individual
Prefix:DR
First Name:MACK
Middle Name:JAY
Last Name:GROVES
Suffix:IV
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:JAY
Other - Middle Name:
Other - Last Name:GROVES
Other - Suffix:IV
Other - Last Name Type:Other Name
Other - Credentials:DPM
Mailing Address - Street 1:802 W 10TH AVE
Mailing Address - Street 2:SUITE 2
Mailing Address - City:COVINGTON
Mailing Address - State:LA
Mailing Address - Zip Code:70433-2352
Mailing Address - Country:US
Mailing Address - Phone:985-867-9605
Mailing Address - Fax:985-867-9001
Practice Address - Street 1:323 S TYLER ST
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:LA
Practice Address - Zip Code:70433-3037
Practice Address - Country:US
Practice Address - Phone:985-867-9605
Practice Address - Fax:985-867-9001
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-30
Last Update Date:2019-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPD190R213E00000X, 213ES0131X
LADPM.190R213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric MedicineGroup - Single Specialty
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1265460877OtherBLUECROSS
LA5Y508Medicare PIN
LA5136070001Medicare NSC