MEDICARE: THERESA ENRIQUEZ, MD, INC

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	261QP2300X	Primary Care Clinic/Center	G49327	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	:	1891195210
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THERESA ENRIQUEZ, MD, INC

Provider Business Mailing Address
First Line	:	210 W 7TH ST
Second Line	:
City	:	OXNARD
State	:	CA
Zip	:	93030-7173
Country	:	US
Telephone Number	:	805-394-0898
Fax Number	:	805-394-0897

Provider Business Practice Location Address
First Line	:	210 W 7TH ST
Second Line	:
City	:	OXNARD
State	:	CA
Zip	:	93030-7173
Country	:	US
Telephone Number	:	805-394-0898
Fax Number	:	805-394-0897

Authorized Official
Title or Position	:	PRESIDENT
Name	:	THERESA ENRIQUEZ
Credential	:	M.D.
Telephone Number	:	805-394-0898

Provider Enumeration Date	:	09/04/2014
Last Update Date	:	09/04/2014

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