Provider Demographics
NPI:1205818622
Name:BOLANOS, JOSE THOMAS (MD)
Entity Type:Individual
Prefix:DR
First Name:JOSE
Middle Name:THOMAS
Last Name:BOLANOS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1555 BARRINGTON RD
Mailing Address - Street 2:DOB 3, #4100
Mailing Address - City:HOFFMAN ESTATES
Mailing Address - State:IL
Mailing Address - Zip Code:60169-1019
Mailing Address - Country:US
Mailing Address - Phone:847-781-1790
Mailing Address - Fax:847-781-9973
Practice Address - Street 1:1555 BARRINGTON RD
Practice Address - Street 2:DOB 3, #4100
Practice Address - City:HOFFMAN ESTATES
Practice Address - State:IL
Practice Address - Zip Code:60169-1019
Practice Address - Country:US
Practice Address - Phone:847-781-1790
Practice Address - Fax:847-781-9973
Is Sole Proprietor?:No
Enumeration Date:2005-11-20
Last Update Date:2022-01-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL036-097424207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036097424Medicaid
IL036097424Medicaid
ILIL1573Medicare PIN
ILH20604Medicare UPIN