Provider Demographics
NPI:1396783510
Name:FLANDERS, DAVID J (MD)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:J
Last Name:FLANDERS
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 1:6446 N JAMESTOWN RD
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61615-2606
Mailing Address - Country:US
Mailing Address - Phone:309-360-0189
Mailing Address - Fax:
Practice Address - Street 1:1320 W BIRD BLVD
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61615-1406
Practice Address - Country:US
Practice Address - Phone:309-360-0189
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-02
Last Update Date:2012-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036068713207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL220011118OtherRAILROAD MEDICARE
IL0360687131Medicaid
ILC40241Medicare UPIN
ILL35535Medicare ID - Type Unspecified
IL220011118OtherRAILROAD MEDICARE
ILL35525Medicare ID - Type Unspecified
ILL63639Medicare ID - Type Unspecified