Provider Demographics
NPI:1942288725
Name:ENNIX, COYNESS L
Entity Type:Individual
Prefix:
First Name:COYNESS
Middle Name:L
Last Name:ENNIX
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 SEA VIEW AVE
Mailing Address - Street 2:
Mailing Address - City:PIEDMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94610-1246
Mailing Address - Country:US
Mailing Address - Phone:510-459-3547
Mailing Address - Fax:510-655-7709
Practice Address - Street 1:101 SEA VIEW AVE
Practice Address - Street 2:
Practice Address - City:PIEDMONT
Practice Address - State:CA
Practice Address - Zip Code:94610-1246
Practice Address - Country:US
Practice Address - Phone:510-459-3547
Practice Address - Fax:510-655-7709
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-03
Last Update Date:2015-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC39990208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
A37274Medicare UPIN