Healthcare Provider Details

I. General information

NPI: 1407884315
Provider Name (Legal Business Name): JACK W GRIFFITH III DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/29/2006
Last Update Date: 07/06/2026
Certification Date: 07/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8273 WHITE OAK AVE
RANCHO CUCAMONGA CA
91730-7671
US

IV. Provider business mailing address

8273 WHITE OAK AVE
RANCHO CUCAMONGA CA
91730-7671
US

V. Phone/Fax

Practice location:
  • Phone: 909-948-8888
  • Fax: 909-948-8839
Mailing address:
  • Phone: 909-948-8888
  • Fax: 909-948-8839

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number20A9405
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number20A9405
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number20A9405
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number20A9405
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: