Healthcare Provider Details

I. General information

NPI: 1265095970
Provider Name (Legal Business Name): JAE DEQUINA DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2019
Last Update Date: 09/16/2024
Certification Date: 09/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10907 MEMORIAL HERMANN DR STE 100
PEARLAND TX
77584-4114
US

IV. Provider business mailing address

10907 MEMORIAL HERMANN DR STE 100
PEARLAND TX
77584-4114
US

V. Phone/Fax

Practice location:
  • Phone: 713-413-6610
  • Fax: 713-413-6601
Mailing address:
  • Phone: 713-413-6610
  • Fax: 713-413-6601

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberT5867
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: