Provider Demographics
NPI:1376542050
Name:JARVIS, DOUGLAS L (DO)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:L
Last Name:JARVIS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:56218 PARKWAY AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:ELKHART
Mailing Address - State:IN
Mailing Address - Zip Code:46516-9326
Mailing Address - Country:US
Mailing Address - Phone:574-293-0005
Mailing Address - Fax:574-293-0019
Practice Address - Street 1:56218 PARKWAY AVE
Practice Address - Street 2:SUITE B
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46516-9326
Practice Address - Country:US
Practice Address - Phone:574-293-0005
Practice Address - Fax:574-293-0019
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-15
Last Update Date:2013-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02001719A2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200133490AMedicaid
IN000000109345OtherANTHEM BCBS #
G39638Medicare UPIN
IN260030534 RR MED#Medicare PIN
IN141570AMedicare PIN