Provider Demographics
NPI:1790722429
Name:ENRIQUEZ, SANTIAGO JR (MD)
Entity Type:Individual
Prefix:
First Name:SANTIAGO
Middle Name:
Last Name:ENRIQUEZ
Suffix:JR
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 1:384 W ENGLEWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:TEANECK
Mailing Address - State:NJ
Mailing Address - Zip Code:07666-2832
Mailing Address - Country:US
Mailing Address - Phone:201-837-6644
Mailing Address - Fax:
Practice Address - Street 1:55 MEADOWLANDS PKWY
Practice Address - Street 2:
Practice Address - City:SECAUCUS
Practice Address - State:NJ
Practice Address - Zip Code:07094-2977
Practice Address - Country:US
Practice Address - Phone:201-392-3100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2020-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA03051800207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ3641805Medicaid
NJ588700Medicare ID - Type Unspecified
NJ3641805Medicaid