Provider Demographics
NPI:1558341933
Name:WARREN, L ROBERT (MD)
Entity Type:Individual
Prefix:
First Name:L
Middle Name:ROBERT
Last Name:WARREN
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 15840
Mailing Address - Street 2:
Mailing Address - City:LOVES PARK
Mailing Address - State:IL
Mailing Address - Zip Code:61132-5840
Mailing Address - Country:US
Mailing Address - Phone:815-654-7772
Mailing Address - Fax:815-654-7009
Practice Address - Street 1:205 CADILLAC CT
Practice Address - Street 2:
Practice Address - City:BELVIDERE
Practice Address - State:IL
Practice Address - Zip Code:61008-1733
Practice Address - Country:US
Practice Address - Phone:815-544-0444
Practice Address - Fax:815-544-0652
Is Sole Proprietor?:No
Enumeration Date:2006-01-20
Last Update Date:2007-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036061249207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036061249Medicaid
E14064Medicare UPIN
IL036061249Medicaid