Provider Demographics
NPI:1780647735
Name:RIES, JEFFREY DEAN (DO)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:DEAN
Last Name:RIES
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 1:1310 SAN BERNARDINO RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-4985
Mailing Address - Country:US
Mailing Address - Phone:909-579-0779
Mailing Address - Fax:909-579-0789
Practice Address - Street 1:1310 SAN BERNARDINO RD
Practice Address - Street 2:SUITE 101
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-4979
Practice Address - Country:US
Practice Address - Phone:909-579-0779
Practice Address - Fax:909-579-0789
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-10
Last Update Date:2012-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A5138174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00AX51380Medicaid
CA00AX51380Medicaid
CAF15239Medicare UPIN