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General NPI Number Information
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NPI Number | 1164916615
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Entity Type | Individual
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Provider Name | ODELAISYS ENRIQUEZ MD
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Gender | Female
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Dates
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Enumeration Date | 06/19/2018
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Last Update Date | 01/06/2026
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Provider Practice Location Address
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Address Line | 100 ARRICOLA AVE
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City | ST AUGUSTINE
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State | FL
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Zip | 32080-4515
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Country | US
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Telephone | 904-825-4368
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Fax |
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Provider Business Mailing Address
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Address Line | 2460 OLD MOULTRIE RD STE 1
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City | ST AUGUSTINE
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State | FL
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Zip | 32086-4198
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Country | US
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Telephone | 786-823-4751
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208D00000X
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Taxonomy Name | General Practice Physician
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License Number | 21065
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License Number State | PR
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Taxonomy #2
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | ME173164
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License Number State | FL
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