Provider Demographics
NPI:1497804454
Name:JAZAYERLI, ROUKAN (MD)
Entity Type:Individual
Prefix:DR
First Name:ROUKAN
Middle Name:
Last Name:JAZAYERLI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10640 W 165TH STREET
Mailing Address - Street 2:
Mailing Address - City:ORLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60467-5653
Mailing Address - Country:US
Mailing Address - Phone:708-364-0261
Mailing Address - Fax:
Practice Address - Street 1:10640 W 165TH STREET
Practice Address - Street 2:
Practice Address - City:ORLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60467-5653
Practice Address - Country:US
Practice Address - Phone:708-364-0261
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2019-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0361188382084P0800X, 2084S0012X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084S0012XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologySleep Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL206975Medicare PIN
IL215684Medicare PIN
IL208306Medicare PIN
IL211335Medicare PIN
IL215683Medicare PIN