Provider Demographics
NPI:1619151552
Name:RICHARD, JASON (DO)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:RICHARD
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12040 N 40TH WAY
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85028-1529
Mailing Address - Country:US
Mailing Address - Phone:602-320-7557
Mailing Address - Fax:
Practice Address - Street 1:3931 E CAMELBACK RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85018-2609
Practice Address - Country:US
Practice Address - Phone:602-687-7858
Practice Address - Fax:602-687-9276
Is Sole Proprietor?:No
Enumeration Date:2007-12-27
Last Update Date:2011-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZR931390200000X
AZ005253207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program