Basic Information
| Provider Information | |||||||||
| NPI: | 1023247822 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHENOUDA | ||||||||
| FirstName: | JACK | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1016 CACTUS CT | ||||||||
| Address2: | |||||||||
| City: | THOUSAND OAKS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913205907 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7175573938 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1600 N ROSE AVE | ||||||||
| Address2: | |||||||||
| City: | OXNARD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 930303722 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7175773938 | ||||||||
| FaxNumber: | 7853546349 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2009 | ||||||||
| LastUpdateDate: | 11/29/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | A140119 | CA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208M00000X | A140119 | CA | Y | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | 068002171 | 01 | KS | MEDICARE PTAN | OTHER | 200962510A | 05 | KS | MEDICAID |