Provider Demographics
NPI:1316938905
Name:HENRIQUEZ, RUBEN DARIO (AUDIOPROSTHOLOGIST)
Entity type:Individual
Prefix:MR
First Name:RUBEN
Middle Name:DARIO
Last Name:HENRIQUEZ
Suffix:
Gender:M
Credentials:AUDIOPROSTHOLOGIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:334 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:HOBOKEN
Mailing Address - State:NJ
Mailing Address - Zip Code:07030-4842
Mailing Address - Country:US
Mailing Address - Phone:201-792-5100
Mailing Address - Fax:201-792-0030
Practice Address - Street 1:334 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:HOBOKEN
Practice Address - State:NJ
Practice Address - Zip Code:07030-4842
Practice Address - Country:US
Practice Address - Phone:201-792-5100
Practice Address - Fax:201-792-0030
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-02
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MG00075800174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ6852602Medicaid