Provider Demographics
NPI:1497758197
Name:JARVIS, KENNETH (DPM)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:
Last Name:JARVIS
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4333 OASIS VALLEY AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89085-2335
Mailing Address - Country:US
Mailing Address - Phone:702-810-1748
Mailing Address - Fax:702-837-8292
Practice Address - Street 1:1200 S 4TH ST STE 111
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89104-1046
Practice Address - Country:US
Practice Address - Phone:702-810-1748
Practice Address - Fax:702-837-8292
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-27
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV0108213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHP00138284OtherRAILROAD MEDICARE
NV100501920Medicaid
NVV36612Medicare PIN
OH2285520001Medicare NSC