Provider Demographics
NPI:1164797270
Name:RUPP, JASON D (MD)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:D
Last Name:RUPP
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:660 S EUCLID AVE
Mailing Address - Street 2:C B 8096
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110-1010
Mailing Address - Country:US
Mailing Address - Phone:314-362-3431
Mailing Address - Fax:314-362-6564
Practice Address - Street 1:517 S EUCLID AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-1007
Practice Address - Country:US
Practice Address - Phone:314-362-3431
Practice Address - Fax:314-362-6564
Is Sole Proprietor?:No
Enumeration Date:2012-03-22
Last Update Date:2018-01-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO2016010391207W00000X
MO2013018535207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1164797270Medicaid
IL1164797270Medicaid