{
"Npi": {
"NPI": "1134425036",
"EntityType": "Organization",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "JACK W. GRIFFITH, III, D.O.",
"LastName": null,
"FirstName": null,
"MiddleName": null,
"NamePrefix": null,
"NameSuffix": null,
"Credential": null,
"OtherOrgName": null,
"OtherOrgNameTypeCode": null,
"OtherLastName": null,
"OtherFirstName": null,
"OtherMiddleName": null,
"OtherNamePrefix": null,
"OtherNameSuffix": null,
"OtherCredential": null,
"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "7365 CARNELIAN STREET",
"SecondLineMailingAddress": "SUITE 137",
"MailingAddressCityName": "RANCHO CUCAMONGA",
"MailingAddressStateName": "CA",
"MailingAddressPostalCode": "91730-1100",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "909-948-8888",
"MailingAddressFaxNumber": "909-948-8888",
"FirstLinePracticeLocationAddress": "7365 CARNELIAN STREET",
"SecondLinePracticeLocationAddress": "SUITE 137",
"PracticeLocationAddressCityName": "RANCHO CUCAMONGA",
"PracticeLocationAddressStateName": "CA",
"PracticeLocationAddressPostalCode": "91730-1100",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "909-948-8888",
"PracticeLocationAddressFaxNumber": "909-948-8888",
"EnumerationDate": "02/10/2011",
"LastUpdateDate": "05/28/2014",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "GRIFFITH",
"AuthorizedOfficialFirstName": "JACK",
"AuthorizedOfficialMiddleName": "WALTER",
"AuthorizedOfficialTitle": "OWNER",
"AuthorizedOfficialNamePrefix": "DR.",
"AuthorizedOfficialNameSuffix": "III",
"AuthorizedOfficialCredential": "D.O.",
"AuthorizedOfficialTelephoneNumber": "949-948-8888",
"Taxonomies": {
"Taxonomy": [
{
"TaxonomyCode": "207ND0101X",
"TaxonomyName": "MOHS-Micrographic Surgery Physician",
"LicenseNumber": "20A9405",
"LicenseNumberStateCode": "CA",
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "207ND0900X",
"TaxonomyName": "Dermatopathology Physician",
"LicenseNumber": "20A9405",
"LicenseNumberStateCode": "CA",
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "207NI0002X",
"TaxonomyName": "Clinical & Laboratory Dermatological Immunology Physician",
"LicenseNumber": "20A9405",
"LicenseNumberStateCode": "CA",
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "207NP0225X",
"TaxonomyName": "Pediatric Dermatology Physician",
"LicenseNumber": "20A9405",
"LicenseNumberStateCode": "CA",
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "207NS0135X",
"TaxonomyName": "Procedural Dermatology Physician",
"LicenseNumber": "20A9405",
"LicenseNumberStateCode": "CA",
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "207N00000X",
"TaxonomyName": "Dermatology Physician",
"LicenseNumber": null,
"LicenseNumberStateCode": null,
"PrimaryTaxonomySwitch": "Y"
}
]
},
"HealthcareProviderTaxonomyGroups": {
"HealthcareProviderTaxonomyGroup": [
{
"HealthcareProviderTaxonomyGroupName": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
"HealthcareProviderTaxonomyGroupDescription": "Single Specialty Group - A business group of one or more individual practitioners, all of who practice with the same area of specialization."
},
{
"HealthcareProviderTaxonomyGroupName": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
"HealthcareProviderTaxonomyGroupDescription": "Single Specialty Group - A business group of one or more individual practitioners, all of who practice with the same area of specialization."
},
{
"HealthcareProviderTaxonomyGroupName": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
"HealthcareProviderTaxonomyGroupDescription": "Single Specialty Group - A business group of one or more individual practitioners, all of who practice with the same area of specialization."
},
{
"HealthcareProviderTaxonomyGroupName": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
"HealthcareProviderTaxonomyGroupDescription": "Single Specialty Group - A business group of one or more individual practitioners, all of who practice with the same area of specialization."
},
{
"HealthcareProviderTaxonomyGroupName": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
"HealthcareProviderTaxonomyGroupDescription": "Single Specialty Group - A business group of one or more individual practitioners, all of who practice with the same area of specialization."
},
{
"HealthcareProviderTaxonomyGroupName": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
"HealthcareProviderTaxonomyGroupDescription": "Single Specialty Group - A business group of one or more individual practitioners, all of who practice with the same area of specialization."
}
]
}
}
}