Provider Demographics
NPI:1639228331
Name:HALL, JACK GREY (OD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:GREY
Last Name:HALL
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:3801 PELANDALE AVE
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95356-8300
Mailing Address - Country:US
Mailing Address - Phone:209-543-0220
Mailing Address - Fax:209-543-0220
Practice Address - Street 1:3801 PELANDALE AVE
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95356-8300
Practice Address - Country:US
Practice Address - Phone:209-543-0220
Practice Address - Fax:209-543-0220
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA6455T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAT10326Medicare UPIN