Healthcare Provider Details

I. General information

NPI: 1790722429
Provider Name (Legal Business Name): SANTIAGO ENRIQUEZ JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2006
Last Update Date: 03/10/2020
Certification Date: 03/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 MEADOWLANDS PKWY
SECAUCUS NJ
07094-2977
US

IV. Provider business mailing address

384 W ENGLEWOOD AVE
TEANECK NJ
07666-2832
US

V. Phone/Fax

Practice location:
  • Phone: 201-392-3100
  • Fax:
Mailing address:
  • Phone: 201-837-6644
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number25MA03051800
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: