Healthcare Provider Details

I. General information

NPI: 1164916615
Provider Name (Legal Business Name): ODELAISYS ENRIQUEZ MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/19/2018
Last Update Date: 01/06/2026
Certification Date: 01/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 ARRICOLA AVE
ST AUGUSTINE FL
32080-4515
US

IV. Provider business mailing address

2460 OLD MOULTRIE RD STE 1
ST AUGUSTINE FL
32086-4198
US

V. Phone/Fax

Practice location:
  • Phone: 904-825-4368
  • Fax:
Mailing address:
  • Phone: 786-823-4751
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number21065
License Number StatePR
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME173164
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: