MEDICARE: JARVIS GATLIN MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	G64705	CA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	110180029	OTHER	CA	RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1558362954
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JARVIS GATLIN MD

Provider Business Mailing Address
First Line	:	12618 HAWTHORNE BLVD.
Second Line	:
City	:	HAWTHORNE
State	:	CA
Zip	:	90250-2325
Country	:	US
Telephone Number	:	310-263-5700
Fax Number	:

Provider Business Practice Location Address
First Line	:	4314 W SLAUSON AVE
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90043-2854
Country	:	US
Telephone Number	:	323-293-7171
Fax Number	:	310-531-2241

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/09/2005
Last Update Date	:	11/15/2021

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