Provider Demographics
NPI:1710912860
Name:GROVE, KATHY D (MD)
Entity Type:Individual
Prefix:
First Name:KATHY
Middle Name:D
Last Name:GROVE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15902 LA MADERA RIO
Mailing Address - Street 2:
Mailing Address - City:HELOTES
Mailing Address - State:TX
Mailing Address - Zip Code:78023-3688
Mailing Address - Country:US
Mailing Address - Phone:210-488-2542
Mailing Address - Fax:210-593-5992
Practice Address - Street 1:500 W FORTH ST
Practice Address - Street 2:
Practice Address - City:ODESSA, TEXAS 79761
Practice Address - State:TX
Practice Address - Zip Code:78215-1137
Practice Address - Country:US
Practice Address - Phone:432-640-1184
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2021-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60652282208600000X
TXL7401208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX6678943OtherCIGNA
TX0097MBOtherBLUE CROSS BLUE SHIELD
TX160045404Medicaid
TX160045402Medicaid
TX3776353OtherAETNA
TX3776353OtherAETNA
TX611465Medicare ID - Type Unspecified