Healthcare Provider Details

I. General information

NPI: 1629102389
Provider Name (Legal Business Name): ENRIQUE LUJAN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/15/2007
Last Update Date: 03/28/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

160 E REDSTONE AVE
CRESTVIEW FL
32539-5348
US

IV. Provider business mailing address

160 E REDSTONE AVE
CRESTVIEW FL
32539-5348
US

V. Phone/Fax

Practice location:
  • Phone: 850-689-0555
  • Fax: 850-689-3531
Mailing address:
  • Phone: 850-689-0555
  • Fax: 850-689-3531

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. ENRIQUE LUJAN
Title or Position: MD OWNER
Credential: M.D.
Phone: 850-689-0555