Provider Demographics
NPI:1578509428
Name:JASENOF, IAN GREG (MD)
Entity Type:Individual
Prefix:
First Name:IAN
Middle Name:GREG
Last Name:JASENOF
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 1:1220 S WOOD ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60608-1202
Mailing Address - Country:US
Mailing Address - Phone:312-413-3282
Mailing Address - Fax:
Practice Address - Street 1:1220 S WOOD ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60608-1202
Practice Address - Country:US
Practice Address - Phone:312-413-1453
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2023-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036083005207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
367830Medicare PIN