Healthcare Provider Details

I. General information

NPI: 1679543870
Provider Name (Legal Business Name): IGOR WESTRA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/23/2006
Last Update Date: 04/23/2021
Certification Date: 04/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1801 NEW HANOVER MEDICAL PARK DR
WILMINGTON NC
28403
US

IV. Provider business mailing address

1801 NEW HANOVER MEDICAL PARK DR
WILMINGTON NC
28403
US

V. Phone/Fax

Practice location:
  • Phone: 910-254-2023
  • Fax: 910-254-0242
Mailing address:
  • Phone: 910-254-2023
  • Fax: 910-254-0242

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number9300370
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code207WX0107X
TaxonomyRetina Specialist (Ophthalmology) Physician
License Number9300370
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: