Provider Demographics
NPI:1952370165
Name:GROVES, JACK D (OD)
Entity type:Individual
Prefix:DR
First Name:JACK
Middle Name:D
Last Name:GROVES
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4649 PLANZ RD
Mailing Address - Street 2:
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93309-5900
Mailing Address - Country:US
Mailing Address - Phone:661-833-4040
Mailing Address - Fax:661-833-6721
Practice Address - Street 1:4649 PLANZ RD
Practice Address - Street 2:
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93309-5900
Practice Address - Country:US
Practice Address - Phone:661-833-4040
Practice Address - Fax:661-833-6721
Is Sole Proprietor?:No
Enumeration Date:2006-03-17
Last Update Date:2024-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA4350 TPA152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0043500Medicaid
CATO9638Medicare UPIN
CASD0043500Medicare ID - Type Unspecified