Provider Demographics
NPI:1700931334
Name:JARAVA, MARCO ALEJANDRO (MD)
Entity Type:Individual
Prefix:MR
First Name:MARCO
Middle Name:ALEJANDRO
Last Name:JARAVA
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 1:848 N ASHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622-5147
Mailing Address - Country:US
Mailing Address - Phone:312-421-1701
Mailing Address - Fax:312-421-1702
Practice Address - Street 1:848 N ASHLAND AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60622-5147
Practice Address - Country:US
Practice Address - Phone:312-421-1701
Practice Address - Fax:312-421-1702
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-24
Last Update Date:2014-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036094915207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036094915Medicaid
ILF64767Medicare UPIN
IL261730Medicare ID - Type Unspecified