Healthcare Provider Details

I. General information

NPI: 1316108533
Provider Name (Legal Business Name): ELIZABETH BRIGHTSTAR ENSCHEDE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2008
Last Update Date: 09/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

202 W 23RD ST 1ST FLOOR
NEW YORK NY
10011-2301
US

IV. Provider business mailing address

PO BOX 95000-2454
PHILADELPHIA PA
19195-2454
US

V. Phone/Fax

Practice location:
  • Phone: 212-352-2600
  • Fax:
Mailing address:
  • Phone: 212-352-2600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number255134
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: