Provider Demographics
NPI:1275698896
Name:ENRIQUEZ, ROMUALDO D (OPTICIAN)
Entity Type:Individual
Prefix:MR
First Name:ROMUALDO
Middle Name:D
Last Name:ENRIQUEZ
Suffix:
Gender:M
Credentials:OPTICIAN
Other - Prefix:MR
Other - First Name:ROMUALDO
Other - Middle Name:D
Other - Last Name:ENRIQUEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OPTICIAN
Mailing Address - Street 1:5805 MISSION ST
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94112-4017
Mailing Address - Country:US
Mailing Address - Phone:415-469-8210
Mailing Address - Fax:415-469-0283
Practice Address - Street 1:5805 MISSION ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94112-4017
Practice Address - Country:US
Practice Address - Phone:415-469-8210
Practice Address - Fax:415-469-0283
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-26
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNA7377156FC0801X
CA20633156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered156FC0801XEye and Vision Services ProvidersTechnician/TechnologistContact Lens Fitter
Not Answered156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADX005745FMedicaid