Healthcare Provider Details

I. General information

NPI: 1376542050
Provider Name (Legal Business Name): DOUGLAS L. JARVIS D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/15/2005
Last Update Date: 07/16/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

56218 PARKWAY AVE SUITE B
ELKHART IN
46516-9326
US

IV. Provider business mailing address

56218 PARKWAY AVE SUITE B
ELKHART IN
46516-9326
US

V. Phone/Fax

Practice location:
  • Phone: 574-293-0005
  • Fax: 574-293-0019
Mailing address:
  • Phone: 574-293-0005
  • Fax: 574-293-0019

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number02001719A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: