Provider Demographics
NPI:1386714889
Name:GROVES, GREGORY A (OD)
Entity type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:A
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 1:107 DOCTORS DR
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:WV
Mailing Address - Zip Code:26330-1720
Mailing Address - Country:US
Mailing Address - Phone:304-842-6226
Mailing Address - Fax:
Practice Address - Street 1:107 DOCTORS DR
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:WV
Practice Address - Zip Code:26330-1720
Practice Address - Country:US
Practice Address - Phone:304-842-6226
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-09
Last Update Date:2010-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV722OD152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0150773000Medicaid
WV0150773000Medicaid
GR0531252Medicare PIN