Provider Demographics
NPI:1992840060
Name:NWANGUMA, CHARLES (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:
Last Name:NWANGUMA
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 1:5502 BRAZOS SPRINGS DR
Mailing Address - Street 2:
Mailing Address - City:SUGAR LAND
Mailing Address - State:TX
Mailing Address - Zip Code:77479-8836
Mailing Address - Country:US
Mailing Address - Phone:281-633-9996
Mailing Address - Fax:
Practice Address - Street 1:601 HOLDEN RD
Practice Address - Street 2:LOGAN REGIONAL CANCER CENTER
Practice Address - City:LOGAN
Practice Address - State:WV
Practice Address - Zip Code:25601-3477
Practice Address - Country:US
Practice Address - Phone:304-831-2500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV219912085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3810003029Medicaid
WVNW4166311Medicare ID - Type Unspecified
G99683Medicare UPIN