Healthcare Provider Details

I. General information

NPI: 1255421483
Provider Name (Legal Business Name): JAY M SHENAQ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/16/2006
Last Update Date: 12/29/2021
Certification Date: 12/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 HIGHWAY 6 STE 10
SUGAR LAND TX
77478-4917
US

IV. Provider business mailing address

16605 SOUTHWEST FWY STE 510
SUGAR LAND TX
77479
US

V. Phone/Fax

Practice location:
  • Phone: 832-532-7100
  • Fax: 832-532-7410
Mailing address:
  • Phone: 832-532-7100
  • Fax: 832-532-7410

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License NumberC52028
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License NumberJ5674
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: