Provider Demographics
NPI:1740654110
Name:LAZAROFF, JAKE (MD)
Entity type:Individual
Prefix:DR
First Name:JAKE
Middle Name:
Last Name:LAZAROFF
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:PO BOX 953593
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63195-3593
Mailing Address - Country:US
Mailing Address - Phone:847-570-4789
Mailing Address - Fax:
Practice Address - Street 1:5841 S MARYLAND AVE # MC5067
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60637-1443
Practice Address - Country:US
Practice Address - Phone:773-702-0549
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-21
Last Update Date:2024-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2024012056207ND0101X, 207N00000X
IL125074787207R00000X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine