Provider Demographics
NPI:1558362954
Name:GATLIN, JARVIS (MD)
Entity Type:Individual
Prefix:
First Name:JARVIS
Middle Name:
Last Name:GATLIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12618 HAWTHORNE BLVD.
Mailing Address - Street 2:
Mailing Address - City:HAWTHORNE
Mailing Address - State:CA
Mailing Address - Zip Code:90250-2325
Mailing Address - Country:US
Mailing Address - Phone:310-263-5700
Mailing Address - Fax:
Practice Address - Street 1:4314 W SLAUSON AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90043-2854
Practice Address - Country:US
Practice Address - Phone:323-293-7171
Practice Address - Fax:310-531-2241
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2021-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG64705207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G647050Medicaid
CA110180029OtherRAILROAD MEDICARE
CAWG64705FMedicare Oscar/Certification
CA110180029Medicare PIN
CA00G647050Medicaid
CA110180029OtherRAILROAD MEDICARE