Provider Demographics
NPI:1962409177
Name:JARVIS, ANGELA LOUISE (MD)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:LOUISE
Last Name:JARVIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3346 PROFESSIONAL PARK DR
Mailing Address - Street 2:
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42303-4551
Mailing Address - Country:US
Mailing Address - Phone:270-685-1066
Mailing Address - Fax:270-685-0881
Practice Address - Street 1:3346 PROFESSIONAL PARK DR
Practice Address - Street 2:
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42303-4551
Practice Address - Country:US
Practice Address - Phone:270-685-1066
Practice Address - Fax:270-685-0881
Is Sole Proprietor?:No
Enumeration Date:2005-07-01
Last Update Date:2021-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY17933207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64179336Medicaid
C68299Medicare UPIN
0688301Medicare ID - Type Unspecified