Provider Demographics
NPI:1891955944
Name:NWANEGBO, EDWARD C (MD)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:C
Last Name:NWANEGBO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7500 RIALTO BLVD STE 1-140
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78735-8534
Mailing Address - Country:US
Mailing Address - Phone:512-730-3056
Mailing Address - Fax:888-730-1925
Practice Address - Street 1:101 E RIDGE RD
Practice Address - Street 2:
Practice Address - City:MCALLEN
Practice Address - State:TX
Practice Address - Zip Code:78503
Practice Address - Country:US
Practice Address - Phone:512-730-3056
Practice Address - Fax:888-730-1925
Is Sole Proprietor?:No
Enumeration Date:2008-06-12
Last Update Date:2023-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301099056207Q00000X
IAR-8307207Q00000X
TXP20906208M00000X
TXP2906207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX299532603Medicaid
TX00778YOtherMEDICARE CLINIC B GROUP
TX162693901OtherLHC FAMILY MEDICINE MEDICAID
TX299532602Medicaid
MI1891955944Medicaid
TX8DG081OtherBCBS LHC
TX299532603Medicaid
268209Medicare Oscar/Certification
MIC36088116Medicare PIN
TX00778YOtherMEDICARE CLINIC B GROUP