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 1:719 E NICHOLS CV
Mailing Address - Street 2:
Mailing Address - City:MILLCREEK
Mailing Address - State:UT
Mailing Address - Zip Code:84106-4628
Mailing Address - Country:US
Mailing Address - Phone:317-690-8847
Mailing Address - Fax:314-362-6564
Practice Address - Street 1:875 COUNTRY HILLS DR
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-2200
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:2025-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10392993-1205207W00000X
MO2016010391207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1164797270Medicaid
MO1164797270Medicaid