Provider Demographics
NPI:1740580703
Name:EDGAR ENRIQUEZ, MD INC.
Entity Type:Organization
Organization Name:EDGAR ENRIQUEZ, MD INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:EDGAR
Authorized Official - Middle Name:ANTONIO
Authorized Official - Last Name:ENRIQUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-435-4450
Mailing Address - Street 1:PO BOX 367
Mailing Address - Street 2:
Mailing Address - City:SOUTH PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91031-0367
Mailing Address - Country:US
Mailing Address - Phone:661-253-1353
Mailing Address - Fax:661-253-1387
Practice Address - Street 1:27420 TOURNEY RD
Practice Address - Street 2:SUITE 210
Practice Address - City:VALENCIA
Practice Address - State:CA
Practice Address - Zip Code:91355-5601
Practice Address - Country:US
Practice Address - Phone:661-253-1353
Practice Address - Fax:661-253-1387
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-25
Last Update Date:2010-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA80489208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty