Provider Demographics
NPI:1891759403
Name:BOQUIN, ENRIQUE M (MD)
Entity type:Individual
Prefix:DR
First Name:ENRIQUE
Middle Name:M
Last Name:BOQUIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 VALE TERRACE DR
Mailing Address - Street 2:
Mailing Address - City:VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:92084-5218
Mailing Address - Country:US
Mailing Address - Phone:760-631-5000
Mailing Address - Fax:760-414-3713
Practice Address - Street 1:1000 VALE TERRACE DR
Practice Address - Street 2:
Practice Address - City:VISTA
Practice Address - State:CA
Practice Address - Zip Code:92084-5218
Practice Address - Country:US
Practice Address - Phone:760-631-5000
Practice Address - Fax:760-414-3713
Is Sole Proprietor?:No
Enumeration Date:2006-04-12
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC52564174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1013048240Medicaid
MI031511OtherMICHIGAN STATE LICENSE #
MI1108211371OtherBLUE CROSS/BLUE SHIELD
MIAB9107411OtherDEA
MIA73444Medicare UPIN
MI08211377111Medicare ID - Type Unspecified