Provider Demographics
NPI:1467449108
Name:ALCANTARA, ENEDINA ENRIQUEZ (MD)
Entity Type:Individual
Prefix:
First Name:ENEDINA
Middle Name:ENRIQUEZ
Last Name:ALCANTARA
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 1:1300 W TERRELL AVE FL 2
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-2820
Mailing Address - Country:US
Mailing Address - Phone:817-820-4906
Mailing Address - Fax:817-820-4815
Practice Address - Street 1:1300 W TERRELL AVE FL 2
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-2820
Practice Address - Country:US
Practice Address - Phone:817-820-4906
Practice Address - Fax:817-820-4815
Is Sole Proprietor?:No
Enumeration Date:2005-09-27
Last Update Date:2012-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA36397174400000X
IL036101575207R00000X
TXM7817207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX192733702Medicaid
P00910166Medicare UPIN
TXTXB157102Medicare PIN
TXTXB157104Medicare PIN
TXTXB110652Medicare PIN
TXTXB157103Medicare PIN
ILH40899Medicare UPIN