Healthcare Provider Details

I. General information

NPI: 1306140439
Provider Name (Legal Business Name): JARED I DARVEAUX MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/04/2011
Last Update Date: 05/28/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

311 GUNDERSEN DR
ONALASKA WI
54650
US

IV. Provider business mailing address

1836 SOUTH AVENUE
LA CROSSE WI
54601
US

V. Phone/Fax

Practice location:
  • Phone: 608-775-8100
  • Fax:
Mailing address:
  • Phone: 608-782-7300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RA0201X
TaxonomyAllergy & Immunology (Internal Medicine) Physician
License Number60467-20
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: