Healthcare Provider Details

I. General information

NPI: 1083274997
Provider Name (Legal Business Name): JASON LAFAVE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/13/2019
Last Update Date: 11/15/2023
Certification Date: 11/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1801 W TAYLOR ST STE 2E
CHICAGO IL
60612-4795
US

IV. Provider business mailing address

1801 W TAYLOR ST STE 2E
CHICAGO IL
60612-4795
US

V. Phone/Fax

Practice location:
  • Phone: 312-996-7416
  • Fax:
Mailing address:
  • Phone: 312-996-7416
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036164445
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: