Provider Demographics
NPI:1144220047
Name:MEJIA, ENRIQUE F (MD)
Entity Type:Individual
Prefix:
First Name:ENRIQUE
Middle Name:F
Last Name:MEJIA
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 1:12314 LIBERTY AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH RICHMOND HILL
Mailing Address - State:NY
Mailing Address - Zip Code:11419-2116
Mailing Address - Country:US
Mailing Address - Phone:718-843-8844
Mailing Address - Fax:718-843-7681
Practice Address - Street 1:12314 LIBERTY AVE
Practice Address - Street 2:
Practice Address - City:SOUTH RICHMOND HILL
Practice Address - State:NY
Practice Address - Zip Code:11419-2116
Practice Address - Country:US
Practice Address - Phone:718-843-8844
Practice Address - Fax:718-843-7681
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY152955208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00757171Medicaid
NYB88618Medicare UPIN