Provider Demographics
NPI:1225038573
Name:ENRIQUEZ, ERIC A (MD)
Entity Type:Individual
Prefix:DR
First Name:ERIC
Middle Name:A
Last Name:ENRIQUEZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:14623 HAWTHORNE BLVD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:LAWNDALE
Mailing Address - State:CA
Mailing Address - Zip Code:90260-1581
Mailing Address - Country:US
Mailing Address - Phone:310-973-8863
Mailing Address - Fax:310-973-1623
Practice Address - Street 1:14623 HAWTHORNE BLVD
Practice Address - Street 2:SUITE 202
Practice Address - City:LAWNDALE
Practice Address - State:CA
Practice Address - Zip Code:90260-1581
Practice Address - Country:US
Practice Address - Phone:310-973-8863
Practice Address - Fax:310-973-1623
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-28
Last Update Date:2010-04-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA82702207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A827020Medicaid
CA00A827020Medicaid
CAI15865Medicare UPIN