Healthcare Provider Details

I. General information

NPI: 1992712384
Provider Name (Legal Business Name): D. MICHAEL JERVIS DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

551 NATIONAL HEALTH CARE DR
DAYTONA BEACH FL
32114-1495
US

IV. Provider business mailing address

551 NATIONAL HEALTH CARE DR
DAYTONA BEACH FL
32114-1495
US

V. Phone/Fax

Practice location:
  • Phone: 386-323-7500
  • Fax:
Mailing address:
  • Phone: 386-323-7500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOS0006873
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: