Provider Demographics
NPI:1184908501
Name:UGWA, VICTOR O
Entity type:Individual
Prefix:
First Name:VICTOR
Middle Name:O
Last Name:UGWA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2775 VILLA CREEK DR
Mailing Address - Street 2:STE 123
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75234-7432
Mailing Address - Country:US
Mailing Address - Phone:972-241-8633
Mailing Address - Fax:972-243-5482
Practice Address - Street 1:2775 VILLA CREEK DR
Practice Address - Street 2:STE 123
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75234-7432
Practice Address - Country:US
Practice Address - Phone:972-241-8633
Practice Address - Fax:972-243-5482
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-04
Last Update Date:2011-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376G00000XNursing Service Related ProvidersNursing Home Administrator
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX453162Medicare PIN