Provider Demographics
NPI:1265480131
Name:JAY, KIERAN M (MD)
Entity Type:Individual
Prefix:
First Name:KIERAN
Middle Name:M
Last Name:JAY
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 1:611 E STAR CT A
Mailing Address - Street 2:
Mailing Address - City:MONTROSE
Mailing Address - State:CO
Mailing Address - Zip Code:81401-6701
Mailing Address - Country:US
Mailing Address - Phone:970-249-4321
Mailing Address - Fax:970-249-2339
Practice Address - Street 1:611 E STAR CT A
Practice Address - Street 2:
Practice Address - City:MONTROSE
Practice Address - State:CO
Practice Address - Zip Code:81401-6701
Practice Address - Country:US
Practice Address - Phone:970-249-4321
Practice Address - Fax:970-249-2339
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2008-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO31910174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO31910OtherLICENCE
COP00324337OtherPALMETTA GBA RAILROAD MED
CO01319102Medicaid
CO01319102Medicaid
COP00324337OtherPALMETTA GBA RAILROAD MED