Provider Demographics
NPI:1922106640
Name:FLORES, EFRAIN (MD)
Entity Type:Individual
Prefix:
First Name:EFRAIN
Middle Name:
Last Name:FLORES
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 1:805 BLANDFORD AVE
Mailing Address - Street 2:
Mailing Address - City:NEW LENOX
Mailing Address - State:IL
Mailing Address - Zip Code:60451-8615
Mailing Address - Country:US
Mailing Address - Phone:815-685-6638
Mailing Address - Fax:
Practice Address - Street 1:215 REMINGTON BLVD
Practice Address - Street 2:SUITE H
Practice Address - City:BOLINGBROOK
Practice Address - State:IL
Practice Address - Zip Code:60440-3656
Practice Address - Country:US
Practice Address - Phone:630-226-9407
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2012-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036106595208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036106595Medicaid
IL036106595Medicaid