MEDICARE: VICTOR NWILOH PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1386068104
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VICTOR NWILOH PA

Provider Business Mailing Address
First Line	:	1475 HERITAGE PKWY
Second Line	:	225
City	:	MANSFIELD
State	:	TX
Zip	:	76063-2735
Country	:	US
Telephone Number	:	817-453-7522
Fax Number	:	866-665-6659

Provider Business Practice Location Address
First Line	:	1475 HERITAGE PKWY
Second Line	:	SUITE 225
City	:	MANSFIELD
State	:	TX
Zip	:	76063-2735
Country	:	US
Telephone Number	:	817-453-7522
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	VICTOR M NWILOH
Credential	:	MD
Telephone Number	:	817-453-7522

Provider Enumeration Date	:	02/13/2014
Last Update Date	:	01/19/2016

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