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General NPI Number Information
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NPI Number | 1740654110
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Entity Type | Individual
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Provider Name | JAKE LAZAROFF MD
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Gender | Male
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Dates
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Enumeration Date | 11/21/2015
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Last Update Date | 07/26/2024
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Provider Practice Location Address
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Address Line | 5841 S MARYLAND AVE # MC5067
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City | CHICAGO
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State | IL
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Zip | 60637-1443
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Country | US
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Telephone | 773-702-0549
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 953593
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City | SAINT LOUIS
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State | MO
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Zip | 63195-3593
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Country | US
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Telephone | 847-570-4789
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207ND0101X
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Taxonomy Name | MOHS-Micrographic Surgery Physician
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License Number | 2024012056
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License Number State | MO
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Taxonomy #2
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | 125074787
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License Number State | IL
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Taxonomy #3
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Taxonomy Code | 207N00000X
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Taxonomy Name | Dermatology Physician
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License Number | 125074787
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License Number State | IL
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Taxonomy #4
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Taxonomy Code | 207N00000X
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Taxonomy Name | Dermatology Physician
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License Number | 2024012056
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License Number State | MO
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