Healthcare Provider Details

I. General information

NPI: 1780139691
Provider Name (Legal Business Name): EMILE G. SHENOUDA MD, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/20/2016
Last Update Date: 08/20/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10132 CALIFORNIA AVE
SOUTH GATE CA
90280-6008
US

IV. Provider business mailing address

10132 CALIFORNIA AVE
SOUTH GATE CA
90280-6008
US

V. Phone/Fax

Practice location:
  • Phone: 323-566-4411
  • Fax: 323-566-0390
Mailing address:
  • Phone: 323-566-4411
  • Fax: 323-566-0390

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA56273
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberA56273
License Number StateCA

VIII. Authorized Official

Name: DR. EMILE GEORGE SHENOUDA
Title or Position: PRESIDENT
Credential: M.D.
Phone: 323-566-4411