Healthcare Provider Details

I. General information

NPI: 1942288725
Provider Name (Legal Business Name): COYNESS L. ENNIX
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/03/2006
Last Update Date: 11/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 SEA VIEW AVE
PIEDMONT CA
94610-1246
US

IV. Provider business mailing address

101 SEA VIEW AVE
PIEDMONT CA
94610-1246
US

V. Phone/Fax

Practice location:
  • Phone: 510-459-3547
  • Fax: 510-655-7709
Mailing address:
  • Phone: 510-459-3547
  • Fax: 510-655-7709

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License NumberC39990
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: