Provider Demographics
NPI:1043417611
Name:RIIS, JACOB (MD)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:RIIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:355 MDG
Mailing Address - Street 2:4175 SOUTH ALAMO AVE
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85707
Mailing Address - Country:US
Mailing Address - Phone:520-228-2721
Mailing Address - Fax:
Practice Address - Street 1:355 MDG
Practice Address - Street 2:4175 SOUTH ALAMO AVE
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85707
Practice Address - Country:US
Practice Address - Phone:520-228-2721
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-28
Last Update Date:2020-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 103069207X00000X, 208D00000X
NHRT 1712208600000X
VA390200000X
FLME103069207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program