Healthcare Provider Details

I. General information

NPI: 1740654110
Provider Name (Legal Business Name): JAKE LAZAROFF MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/21/2015
Last Update Date: 07/26/2024
Certification Date: 07/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5841 S MARYLAND AVE # MC5067
CHICAGO IL
60637-1443
US

IV. Provider business mailing address

PO BOX 953593
SAINT LOUIS MO
63195-3593
US

V. Phone/Fax

Practice location:
  • Phone: 773-702-0549
  • Fax:
Mailing address:
  • Phone: 847-570-4789
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number2024012056
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number125074787
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number125074787
License Number StateIL
# 4
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number2024012056
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: