Provider Demographics
NPI:1376632547
Name:ENRIQUEZ, EDGAR ANTONIO (MD)
Entity Type:Individual
Prefix:
First Name:EDGAR
Middle Name:ANTONIO
Last Name:ENRIQUEZ
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 1:1401 MONTEREY RD
Mailing Address - Street 2:APT E
Mailing Address - City:SOUTH PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91030-3845
Mailing Address - Country:US
Mailing Address - Phone:310-435-4450
Mailing Address - Fax:
Practice Address - Street 1:25775 MCBEAN PKWY
Practice Address - Street 2:SUITE 216
Practice Address - City:VALENCIA
Practice Address - State:CA
Practice Address - Zip Code:91355-3708
Practice Address - Country:US
Practice Address - Phone:661-253-1353
Practice Address - Fax:661-253-1387
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-12
Last Update Date:2007-09-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA80489208600000X, 2086S0127X, 2086X0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086X0206XAllopathic & Osteopathic PhysiciansSurgerySurgical Oncology
No208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma Surgery