Provider Demographics
NPI:1952395972
Name:ENRIQUEZ, BERNARDITA R (MD)
Entity Type:Individual
Prefix:
First Name:BERNARDITA
Middle Name:R
Last Name:ENRIQUEZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 W RIVER DR
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52801-1014
Mailing Address - Country:US
Mailing Address - Phone:563-336-3000
Mailing Address - Fax:563-327-2102
Practice Address - Street 1:2750 11TH ST
Practice Address - Street 2:
Practice Address - City:ROCK ISLAND
Practice Address - State:IL
Practice Address - Zip Code:61201-5216
Practice Address - Country:US
Practice Address - Phone:563-327-2100
Practice Address - Fax:563-327-2102
Is Sole Proprietor?:No
Enumeration Date:2005-09-06
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-066809208000000X, 2080P0204X
IA34871208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080P0204XAllopathic & Osteopathic PhysiciansPediatricsPediatric Emergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA421060724OtherBILLING TAX ID# FOR CHC
IA0568980Medicaid
IL421606724A5OtherJOHN DEERE HEALTH
IA0568998Medicaid
IL421060724005Medicaid
IL036066809Medicaid
IL8122859OtherILLINOIS BC/BS
IA93612OtherIOWA BC/BS SEEN IN RI
093469OtherHEALTH ALLIANCE #
IL336031012OtherCONTROLLED SUBSTANCE #
ILIL01A5OtherJOHN DEERE EDI#
ILIL01A5OtherJOHN DEERE EDI#
ILIL01A5OtherJOHN DEERE EDI#
IL336031012OtherCONTROLLED SUBSTANCE #
IL421606724A5OtherJOHN DEERE HEALTH