Provider Demographics
NPI:1356399646
Name:ISIDRO, ENRIQUE (MD)
Entity type:Individual
Prefix:
First Name:ENRIQUE
Middle Name:
Last Name:ISIDRO
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 1:6391 ROOSEVELT HWY
Mailing Address - Street 2:
Mailing Address - City:WARM SPRINGS
Mailing Address - State:GA
Mailing Address - Zip Code:31830-2281
Mailing Address - Country:US
Mailing Address - Phone:706-655-5302
Mailing Address - Fax:706-655-5303
Practice Address - Street 1:6391 ROOSEVELT HWY
Practice Address - Street 2:
Practice Address - City:WARM SPRINGS
Practice Address - State:GA
Practice Address - Zip Code:31830-2281
Practice Address - Country:US
Practice Address - Phone:706-655-5337
Practice Address - Fax:706-655-5299
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2010-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA49617208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00898147BMedicaid
GA25BBFTCMedicare ID - Type Unspecified
GA00898147BMedicaid