Provider Demographics
NPI:1457595258
Name:MWANIKA, BENJAMIN ISAAC (DO)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:ISAAC
Last Name:MWANIKA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11511 SHADOW CREEK PKWY
Mailing Address - Street 2:
Mailing Address - City:PEARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:77584-7298
Mailing Address - Country:US
Mailing Address - Phone:713-442-0000
Mailing Address - Fax:
Practice Address - Street 1:2509 PLEASANT RUN DR
Practice Address - Street 2:
Practice Address - City:HARRISONBURG
Practice Address - State:VA
Practice Address - Zip Code:22801-8720
Practice Address - Country:US
Practice Address - Phone:540-689-5500
Practice Address - Fax:540-757-7574
Is Sole Proprietor?:No
Enumeration Date:2009-04-23
Last Update Date:2022-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXT9755207QS0010X, 207Q00000X
VA0102203559207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1457595258Medicaid