Provider Demographics
NPI:1528216447
Name:ENRIQUEZ, BRIAN MATEO (DO)
Entity Type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:MATEO
Last Name:ENRIQUEZ
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:509 MED TECH PKWY STE 100
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-2579
Mailing Address - Country:US
Mailing Address - Phone:423-302-6565
Mailing Address - Fax:423-952-2175
Practice Address - Street 1:24530 FALCON PLACE BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:ABINGDON
Practice Address - State:VA
Practice Address - Zip Code:24211
Practice Address - Country:US
Practice Address - Phone:276-619-0075
Practice Address - Fax:276-619-0077
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-04
Last Update Date:2018-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2691207Q00000X
HI1599207Q00000X
TN2681208M00000X
VA0102203391208M00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN103I082838Medicare PIN
VAVVL496B288Medicare PIN