Provider Demographics
NPI:1285687673
Name:BOLANOS, LUIS A (MD)
Entity Type:Individual
Prefix:DR
First Name:LUIS
Middle Name:A
Last Name:BOLANOS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1256 WATERFORD DR STE 230
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:IL
Mailing Address - Zip Code:60504-4511
Mailing Address - Country:US
Mailing Address - Phone:630-499-2404
Mailing Address - Fax:630-692-5518
Practice Address - Street 1:2121 RIDGE AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:AURORA
Practice Address - State:IL
Practice Address - Zip Code:60504-7000
Practice Address - Country:US
Practice Address - Phone:630-820-7100
Practice Address - Fax:630-264-2524
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2019-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036090032208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0360900323Medicare ID - Type Unspecified