Provider Demographics
NPI:1689832610
Name:COYNESS L. ENNIX JR., M.D., INC.
Entity Type:Organization
Organization Name:COYNESS L. ENNIX JR., M.D., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:COYNESS
Authorized Official - Middle Name:LOYAL
Authorized Official - Last Name:ENNIX
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:510-465-5500
Mailing Address - Street 1:3300 WEBSTER ST
Mailing Address - Street 2:SUITE 404
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94609-3117
Mailing Address - Country:US
Mailing Address - Phone:510-465-5500
Mailing Address - Fax:510-835-2682
Practice Address - Street 1:3300 WEBSTER ST
Practice Address - Street 2:SUITE 404
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94609-3117
Practice Address - Country:US
Practice Address - Phone:510-465-5500
Practice Address - Fax:510-835-2682
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-27
Last Update Date:2008-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC39990208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ03450ZMedicare PIN