Provider Demographics
NPI:1508108945
Name:WALTERS, JARVIS WAYNE (DO)
Entity Type:Individual
Prefix:
First Name:JARVIS
Middle Name:WAYNE
Last Name:WALTERS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:14155 N 83RD AVE STE 105
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85381-5640
Mailing Address - Country:US
Mailing Address - Phone:623-486-7700
Mailing Address - Fax:316-945-9131
Practice Address - Street 1:14155 N 83RD AVE STE 105
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85381-5640
Practice Address - Country:US
Practice Address - Phone:623-486-7700
Practice Address - Fax:623-486-7703
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-25
Last Update Date:2023-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCDO034734208600000X
KS05-42508208600000X
AZ008056208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery