Basic Information
| Provider Information | |||||||||
| NPI: | 1952557282 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NWAIGWE | ||||||||
| FirstName: | EBUBE | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 731912 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 753731912 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9038777777 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 11937 US HIGHWAY 271 | ||||||||
| Address2: | |||||||||
| City: | TYLER | ||||||||
| State: | TX | ||||||||
| PostalCode: | 757083154 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9038777777 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/18/2008 | ||||||||
| LastUpdateDate: | 12/27/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | Q9219 | TX | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 0083708 | 05 | OH | MEDICAID |