Provider Demographics
NPI:1023258969
Name:FLORES, RANDY (DO)
Entity type:Individual
Prefix:
First Name:RANDY
Middle Name:
Last Name:FLORES
Suffix:
Gender:M
Credentials:DO
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 35380
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89133-5380
Mailing Address - Country:US
Mailing Address - Phone:702-877-8661
Mailing Address - Fax:702-258-8132
Practice Address - Street 1:2450 W CHARLESTON BLVD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89102-2179
Practice Address - Country:US
Practice Address - Phone:702-877-8660
Practice Address - Fax:702-258-1322
Is Sole Proprietor?:No
Enumeration Date:2009-03-05
Last Update Date:2015-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TXN2499207L00000X
NVDO1468207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ577288Medicaid
NV1023258969Medicaid
AZ577288Medicaid
NVDS959ZMedicare PIN