Healthcare Provider Details

I. General information

NPI: 1952558041
Provider Name (Legal Business Name): ENN MAGI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/20/2008
Last Update Date: 08/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5887 BROCKTON AVE
RIVERSIDE CA
92506-1858
US

IV. Provider business mailing address

5887 BROCKTON AVE
RIVERSIDE CA
92506-1858
US

V. Phone/Fax

Practice location:
  • Phone: 951-218-4167
  • Fax:
Mailing address:
  • Phone: 951-218-4167
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberG21241
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number7530
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: