Healthcare Provider Details

I. General information

NPI: 1306672365
Provider Name (Legal Business Name): JEANNOT KEKEDJIAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2024
Last Update Date: 09/09/2024
Certification Date: 09/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1515 HOLCOMBE BLVD UNIT 428
HOUSTON TX
77030-4028
US

IV. Provider business mailing address

1755 WYNDALE ST APT 401
HOUSTON TX
77030-4169
US

V. Phone/Fax

Practice location:
  • Phone: 713-516-3521
  • Fax:
Mailing address:
  • Phone: 713-501-3527
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberBP10087611
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: