Provider Demographics
NPI:1265464531
Name:JARVIS, NICOLE TERESA (MD)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:TERESA
Last Name:JARVIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2417 WESTPORT DR
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73069-6337
Mailing Address - Country:US
Mailing Address - Phone:405-701-2424
Mailing Address - Fax:405-701-2455
Practice Address - Street 1:2417 WESTPORT DR
Practice Address - Street 2:
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73069-6337
Practice Address - Country:US
Practice Address - Phone:405-701-2424
Practice Address - Fax:405-701-2455
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2017-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK23235207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200011880AMedicaid
900522099OtherGROUP MEDICARE ID NBR
OK200011880AMedicaid
OK200011880AMedicaid