Healthcare Provider Details

I. General information

NPI: 1275988933
Provider Name (Legal Business Name): SUNIL KUMAR JEGANATHAN MD, DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2016
Last Update Date: 11/04/2024
Certification Date: 11/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 VISION PARK BLVD STE 240
SHENANDOAH TX
77384-3004
US

IV. Provider business mailing address

111 VISION PARK BLVD STE 240
SHENANDOAH TX
77384-3004
US

V. Phone/Fax

Practice location:
  • Phone: 936-273-6000
  • Fax: 936-273-6022
Mailing address:
  • Phone: 936-273-6000
  • Fax: 936-273-6022

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number2385
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License Number2385
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: