Healthcare Provider Details

I. General information

NPI: 1497101216
Provider Name (Legal Business Name): TRAVIS RICHARD ISRAEL D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/11/2016
Last Update Date: 11/23/2021
Certification Date: 11/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10099 RIDGEGATE PKWY SUITE 120
LONE TREE CO
80124-5531
US

IV. Provider business mailing address

4328 5TH AVE
SAN DIEGO CA
92103-1417
US

V. Phone/Fax

Practice location:
  • Phone: 720-874-2406
  • Fax:
Mailing address:
  • Phone: 858-395-2586
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: