1043210016 NPI number — MR. JORGE ENRIQUEZ MD

Table of content: MR. JORGE ENRIQUEZ MD (NPI 1043210016)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043210016 NPI number — MR. JORGE ENRIQUEZ MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ENRIQUEZ
Provider First Name:
JORGE
Provider Middle Name:
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
ENRIQUEZ
Provider Other First Name:
JORGE
Provider Other Middle Name:
Provider Other Name Prefix Text:
MR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD FACS INC
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1043210016
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/03/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2021 22ND ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BAKERSFIELD
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93301-3802
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
661-864-7076
Provider Business Mailing Address Fax Number:
661-864-7131

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2021 22ND ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BAKERSFIELD
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93301-3802
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
661-864-7076
Provider Business Practice Location Address Fax Number:
661-864-7131
Provider Enumeration Date:
07/29/2005

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208600000X , with the licence number:  A49936 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 00A499360 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".