Basic Information
| Provider Information | |||||||||
| NPI: | 1285884841 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NAVARRETE FAUBLA | ||||||||
| FirstName: | JAIME | ||||||||
| MiddleName: | IGNACIO | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 601 ELMWOOD AVE BOX MED | ||||||||
| Address2: | |||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146420001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5852755863 | ||||||||
| FaxNumber: | 5852735761 | ||||||||
| Practice Location | |||||||||
| Address1: | 1400 PIN OAK DR | ||||||||
| Address2: | |||||||||
| City: | CARTERVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 62918 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6189853333 | ||||||||
| FaxNumber: | 6189851318 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/19/2008 | ||||||||
| LastUpdateDate: | 03/02/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/02/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0000X | 258375 | NY | N | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology | 207RH0003X | 036.144721 | IL | N | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology | 208M00000X | 258375 | NY | N | Allopathic & Osteopathic Physicians | Hospitalist | 207RH0003X | 258375 | NY | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
| ID | Type | State | Issuer | Description | 03357820 | 05 | NY | MEDICAID |