Provider Demographics
NPI:1417947367
Name:ELLER, JARED CALVIN (DO)
Entity Type:Individual
Prefix:DR
First Name:JARED
Middle Name:CALVIN
Last Name:ELLER
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:PO BOX 8100
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97303-0900
Mailing Address - Country:US
Mailing Address - Phone:503-399-2424
Mailing Address - Fax:
Practice Address - Street 1:2531 BOONE RD SE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97306-9675
Practice Address - Country:US
Practice Address - Phone:503-399-2424
Practice Address - Fax:503-585-2961
Is Sole Proprietor?:No
Enumeration Date:2005-10-24
Last Update Date:2017-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A 8527207Q00000X
ORDO29385207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500610933Medicaid
ORP01752519OtherRAILROAD MEDICARE
OR500610933Medicaid