Provider Demographics
NPI:1356923197
Name:RIVERA, JASON ISAIAH (MD)
Entity type:Individual
Prefix:DR
First Name:JASON
Middle Name:ISAIAH
Last Name:RIVERA
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 1:12631 E 17TH AVE STE F496
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80045-2527
Mailing Address - Country:US
Mailing Address - Phone:720-553-2696
Mailing Address - Fax:
Practice Address - Street 1:12631 E 17TH AVE STE F496
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80045-2527
Practice Address - Country:US
Practice Address - Phone:720-553-2696
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-21
Last Update Date:2023-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.0069518207Q00000X, 208D00000X
COTL.0008534390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO029486OtherKAISER COMMERCIAL NUMBER