Healthcare Provider Details

I. General information

NPI: 1396958047
Provider Name (Legal Business Name): JACOB HAIAVY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2007
Last Update Date: 05/04/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8680 MONROE CT #200
RANCHO CUCAMONGA CA
91730-4880
US

IV. Provider business mailing address

8680 MONROE CT. #200
RANCHO CUCAMONGA CA
91730
US

V. Phone/Fax

Practice location:
  • Phone: 909-987-0899
  • Fax: 909-987-9399
Mailing address:
  • Phone: 909-987-0899
  • Fax: 909-987-9399

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberA69766
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: