Healthcare Provider Details

I. General information

NPI: 1417104399
Provider Name (Legal Business Name): SEAN ENIS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/22/2008
Last Update Date: 01/30/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

189 LYMAN PL
ENGLEWOOD NJ
07631-3609
US

IV. Provider business mailing address

189 LYMAN PL
ENGLEWOOD NJ
07631-3609
US

V. Phone/Fax

Practice location:
  • Phone: 917-945-9568
  • Fax:
Mailing address:
  • Phone: 917-945-9568
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number25MA08167000
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number256649
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number25MA8167000
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: