Healthcare Provider Details

I. General information

NPI: 1538367263
Provider Name (Legal Business Name): MIGNON AVENDANO ENECILLA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2007
Last Update Date: 06/19/2025
Certification Date: 06/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 NORTH ST STE 101
GENEVA NY
14456-1561
US

IV. Provider business mailing address

100 KINGS HWY S
ROCHESTER NY
14617-5504
US

V. Phone/Fax

Practice location:
  • Phone: 315-787-5200
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number243069
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number243069
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number243069
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: