MEDICARE: DR. ERIC A. ENRIQUEZ M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	A82702	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1225038573
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ERIC A. ENRIQUEZ M.D.

Provider Business Mailing Address
First Line	:	14623 HAWTHORNE BLVD
Second Line	:	SUITE 202
City	:	LAWNDALE
State	:	CA
Zip	:	90260-1581
Country	:	US
Telephone Number	:	310-973-8863
Fax Number	:	310-973-1623

Provider Business Practice Location Address
First Line	:	14623 HAWTHORNE BLVD
Second Line	:	SUITE 202
City	:	LAWNDALE
State	:	CA
Zip	:	90260-1581
Country	:	US
Telephone Number	:	310-973-8863
Fax Number	:	310-973-1623

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/28/2005
Last Update Date	:	04/30/2010

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