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General NPI Number Information
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NPI Number | 1104126457
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Entity Type | Organization
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Legal Business Name | JACK W. GRIFFITH, III, D.O.
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Dates
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Enumeration Date | 11/02/2010
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Last Update Date | 05/28/2014
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Provider Practice Location Address
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Address Line | 7365 CARNELIAN STREET SUITE 137
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City | RANCHO CUCAMONGA
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State | CA
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Zip | 91730-1100
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Country | US
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Telephone | 909-948-8888
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Fax | 909-948-8839
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Provider Business Mailing Address
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Address Line | 7365 CARNELIAN STREET SUITE 137
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City | RANCHO CUCAMONGA
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State | CA
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Zip | 91730-1100
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Country | US
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Telephone | 909-948-8888
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Fax | 909-948-8839
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Authorized Official
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Title or Position | OWNER
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Name | DR. JACK WALTER GRIFFITH III
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Credential | D.O.
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Telephone | 909-948-8888
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207ND0101X
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Taxonomy Name | MOHS-Micrographic Surgery Physician
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License Number | 20A9405
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 207ND0900X
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Taxonomy Name | Dermatopathology Physician
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License Number | 20A9405
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License Number State | CA
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Taxonomy #3
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Taxonomy Code | 207NI0002X
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Taxonomy Name | Clinical & Laboratory Dermatological Immunology Physician
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License Number | 20A9405
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License Number State | CA
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Taxonomy #4
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Taxonomy Code | 207NP0225X
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Taxonomy Name | Pediatric Dermatology Physician
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License Number | 20A9405
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License Number State | CA
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Taxonomy #5
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Taxonomy Code | 207NS0135X
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Taxonomy Name | Procedural Dermatology Physician
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License Number | 20A9405
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License Number State | CA
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Taxonomy #6
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Taxonomy Code | 207N00000X
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Taxonomy Name | Dermatology Physician
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License Number | 20A9405
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License Number State | CA
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