Provider Demographics
NPI:1306026703
Name:BANEGAS, SHONDA (D O)
Entity Type:Individual
Prefix:
First Name:SHONDA
Middle Name:
Last Name:BANEGAS
Suffix:
Gender:F
Credentials:D O
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5012 S US HIGHWAY 75 STE 110
Mailing Address - Street 2:
Mailing Address - City:DENISON
Mailing Address - State:TX
Mailing Address - Zip Code:75020-4596
Mailing Address - Country:US
Mailing Address - Phone:903-416-6419
Mailing Address - Fax:903-416-6484
Practice Address - Street 1:5012 S US HIGHWAY 75 STE 110
Practice Address - Street 2:
Practice Address - City:DENISON
Practice Address - State:TX
Practice Address - Zip Code:75020-4596
Practice Address - Country:US
Practice Address - Phone:903-416-6419
Practice Address - Fax:903-416-6484
Is Sole Proprietor?:No
Enumeration Date:2007-11-14
Last Update Date:2023-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101016869208600000X
AZ61362086S0129X
TXR76572086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX348242401Medicaid
AZZ161639Medicare PIN