=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396958047
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JACOB HAIAVY M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/08/2007
-----------------------------------------------------
Last Update Date | 05/04/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8680 MONROE CT #200
-----------------------------------------------------
City | RANCHO CUCAMONGA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91730-4880
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-987-0899
-----------------------------------------------------
Fax | 909-987-9399
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8680 MONROE CT. #200
-----------------------------------------------------
City | RANCHO CUCAMONGA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91730
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-987-0899
-----------------------------------------------------
Fax | 909-987-9399
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number | A69766
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------