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 1:550 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:SHAFTER
Mailing Address - State:CA
Mailing Address - Zip Code:93263-2122
Mailing Address - Country:US
Mailing Address - Phone:661-746-2765
Mailing Address - Fax:661-746-5513
Practice Address - Street 1:550 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:SHAFTER
Practice Address - State:CA
Practice Address - Zip Code:93263-2122
Practice Address - Country:US
Practice Address - Phone:661-746-2765
Practice Address - Fax:661-746-5513
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-17
Last Update Date:2007-07-08
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