Provider Demographics
NPI:1649590175
Name:ENRIQUEZ, ROBERT JOHN (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:JOHN
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 1:117 NIXON AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10304-2233
Mailing Address - Country:US
Mailing Address - Phone:502-727-5112
Mailing Address - Fax:
Practice Address - Street 1:3132 JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92110-4421
Practice Address - Country:US
Practice Address - Phone:502-727-5112
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-07
Last Update Date:2015-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA 1262312084P0800X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry