Provider Demographics
NPI:1598806341
Name:MONTCLAIR FAMILY PRACTICE LLC
Entity Type:Organization
Organization Name:MONTCLAIR FAMILY PRACTICE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN, PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:C
Authorized Official - Last Name:FLORES
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:973-743-2321
Mailing Address - Street 1:230 SHERMAN AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:GLEN RIDGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07028-1529
Mailing Address - Country:US
Mailing Address - Phone:973-743-2321
Mailing Address - Fax:973-259-0600
Practice Address - Street 1:230 SHERMAN AVE
Practice Address - Street 2:SUITE A
Practice Address - City:GLEN RIDGE
Practice Address - State:NJ
Practice Address - Zip Code:07028-1529
Practice Address - Country:US
Practice Address - Phone:973-743-2321
Practice Address - Fax:973-259-0600
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-12
Last Update Date:2012-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB05438000207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ689291Medicare ID - Type UnspecifiedNITTI
NJF00016Medicare UPIN
NJF42443Medicare UPIN
NJ184253Medicare ID - Type UnspecifiedFLORES