Healthcare Provider Details

I. General information

NPI: 1982167367
Provider Name (Legal Business Name): VICTOR SHOWALTER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/11/2019
Last Update Date: 06/02/2024
Certification Date: 06/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

509 N ELAM AVE
GREENSBORO NC
27403-1129
US

IV. Provider business mailing address

509 N ELAM AVE
GREENSBORO NC
27403-1129
US

V. Phone/Fax

Practice location:
  • Phone: 336-274-1114
  • Fax:
Mailing address:
  • Phone: 336-274-1114
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number2024-01027
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: