Provider Demographics
NPI:1811156656
Name:GERVAIS, JACK (MD)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:GERVAIS
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:PO BOX 5788
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80217-5788
Mailing Address - Country:US
Mailing Address - Phone:303-202-1280
Mailing Address - Fax:303-202-1281
Practice Address - Street 1:340 PEAK ONE DR.
Practice Address - Street 2:
Practice Address - City:FRISCO
Practice Address - State:CO
Practice Address - Zip Code:80443-0738
Practice Address - Country:US
Practice Address - Phone:970-668-8123
Practice Address - Fax:970-668-2844
Is Sole Proprietor?:No
Enumeration Date:2008-06-06
Last Update Date:2013-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO50036207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ816363Medicaid
20326023101OtherPACIFICARE SECURE HORIZONS
CO73872369Medicaid
P00980274OtherRR MEDICARE
AZ816363Medicaid