Provider Demographics
NPI:1407884315
Name:GRIFFITH, JACK W III (DO)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:W
Last Name:GRIFFITH
Suffix:III
Gender:M
Credentials:DO
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Mailing Address - Street 1:7365 CARNELIAN ST
Mailing Address - Street 2:SUITE 137
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-1158
Mailing Address - Country:US
Mailing Address - Phone:909-948-8888
Mailing Address - Fax:909-948-8839
Practice Address - Street 1:7365 CARNELIAN ST
Practice Address - Street 2:SUITE 137
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-1158
Practice Address - Country:US
Practice Address - Phone:909-948-8888
Practice Address - Fax:909-948-8839
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-29
Last Update Date:2014-11-07
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CA20A9405207P00000X, 207R00000X, 207N00000X, 207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00AX94050Medicaid
CAI54825Medicare UPIN
CA020A94050Medicare PIN