Provider Demographics
NPI:1205198421
Name:MWAMBA, KHOTWANAEYA A (MD)
Entity type:Individual
Prefix:
First Name:KHOTWANAEYA
Middle Name:A
Last Name:MWAMBA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KHOTWANAEYA
Other - Middle Name:A
Other - Last Name:COHEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:523 S FANNIN AVE
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75702-8204
Mailing Address - Country:US
Mailing Address - Phone:903-535-9041
Mailing Address - Fax:
Practice Address - Street 1:2231 W GENTRY PKWY
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75702-2809
Practice Address - Country:US
Practice Address - Phone:903-535-9041
Practice Address - Fax:903-787-5098
Is Sole Proprietor?:No
Enumeration Date:2012-06-13
Last Update Date:2025-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXR6634208000000X
AZ49873208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ016737Medicaid