Healthcare Provider Details

I. General information

NPI: 1952395972
Provider Name (Legal Business Name): BERNARDITA R ENRIQUEZ M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/06/2005
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2750 11TH ST
ROCK ISLAND IL
61201-5216
US

IV. Provider business mailing address

500 W RIVER DR
DAVENPORT IA
52801-1014
US

V. Phone/Fax

Practice location:
  • Phone: 563-327-2100
  • Fax: 563-327-2102
Mailing address:
  • Phone: 563-336-3000
  • Fax: 563-327-2102

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036-066809
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number34871
License Number StateIA
# 3
Primary TaxonomyN
Taxonomy Code2080P0204X
TaxonomyPediatric Emergency Medicine (Pediatrics) Physician
License Number036-066809
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: