Provider Demographics
NPI:1538367263
Name:ENECILLA, MIGNON AVENDANO (MD)
Entity type:Individual
Prefix:
First Name:MIGNON
Middle Name:AVENDANO
Last Name:ENECILLA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:959 PANORAMA TRL S STE 100
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14625-2382
Mailing Address - Country:US
Mailing Address - Phone:585-276-9361
Mailing Address - Fax:585-248-3703
Practice Address - Street 1:959 PANORAMA TRL S STE 100
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14625-2382
Practice Address - Country:US
Practice Address - Phone:585-276-9361
Practice Address - Fax:585-248-3703
Is Sole Proprietor?:No
Enumeration Date:2007-07-03
Last Update Date:2023-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY243069207QG0300X, 363AM0700X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical