Provider Demographics
NPI:1235170671
Name:TARVER, JERRY M (MD)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:M
Last Name:TARVER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 11538
Mailing Address - Street 2:
Mailing Address - City:KILLEEN
Mailing Address - State:TX
Mailing Address - Zip Code:76547-1538
Mailing Address - Country:US
Mailing Address - Phone:254-245-9177
Mailing Address - Fax:254-245-9178
Practice Address - Street 1:4351 RIDGEMONT DR STE A
Practice Address - Street 2:
Practice Address - City:ABILENE
Practice Address - State:TX
Practice Address - Zip Code:79606
Practice Address - Country:US
Practice Address - Phone:254-245-9175
Practice Address - Fax:254-213-7771
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXH2971207L00000X, 207LP2900X, 208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX137430811Medicaid
VTOVN2032Medicaid
VTOVN2032Medicaid
VTC22490Medicare UPIN
VN2032Medicare PIN
C22490Medicare UPIN