Provider Demographics
NPI:1609948454
Name:FLORES, DIVINA GRACIA J (MD)
Entity Type:Individual
Prefix:
First Name:DIVINA
Middle Name:GRACIA J
Last Name:FLORES
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:DIVINA GRACIA
Other - Middle Name:VALLESTEROS
Other - Last Name:DE JESUS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1800 HARRISON ST FL 7
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94612-3466
Mailing Address - Country:US
Mailing Address - Phone:510-625-6262
Mailing Address - Fax:
Practice Address - Street 1:7373 WEST LN
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95210-3377
Practice Address - Country:US
Practice Address - Phone:209-476-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2022-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA757822084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A757820Medicaid
H92058Medicare UPIN
00A757820Medicare ID - Type Unspecified