=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326386996
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TINA ANNE MARIE SHENOUDA MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/16/2013
-----------------------------------------------------
Last Update Date | 05/06/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 545 GULFGATE CENTER MALL
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77087-3023
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-846-7209
-----------------------------------------------------
Fax | 833-845-2871
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6416 OLD WINTER GARDEN RD
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32835-1348
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-751-7288
-----------------------------------------------------
Fax | 407-770-0661
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 0101252936
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | S1268
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | ME 114649
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------