Provider Demographics
NPI:1023010907
Name:ENRILE, BENEDICTA G (MD)
Entity Type:Individual
Prefix:
First Name:BENEDICTA
Middle Name:G
Last Name:ENRILE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:555 S 18TH ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43205-2654
Mailing Address - Country:US
Mailing Address - Phone:614-722-2438
Mailing Address - Fax:614-722-4966
Practice Address - Street 1:555 S 18TH ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43205-2654
Practice Address - Country:US
Practice Address - Phone:614-722-2438
Practice Address - Fax:614-722-4966
Is Sole Proprietor?:No
Enumeration Date:2005-08-11
Last Update Date:2008-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH350348432080P0008X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0008XAllopathic & Osteopathic PhysiciansPediatricsNeurodevelopmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0105149000Medicaid
KY64789043Medicaid
OH0252524Medicaid
WV0105149000Medicaid
KY64789043Medicaid