Provider Demographics
NPI:1164916615
Name:ENRIQUEZ HERNANDEZ, ODELAISYS (MD)
Entity Type:Individual
Prefix:
First Name:ODELAISYS
Middle Name:
Last Name:ENRIQUEZ HERNANDEZ
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 1:14401 SW 33RD ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33175-7471
Mailing Address - Country:US
Mailing Address - Phone:305-206-5452
Mailing Address - Fax:
Practice Address - Street 1:2007 PALM BEACH LAKES BLVD
Practice Address - Street 2:
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33409-6501
Practice Address - Country:US
Practice Address - Phone:561-688-5808
Practice Address - Fax:561-420-8560
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-19
Last Update Date:2019-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR21065208D00000X
FLACN1106207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice