Healthcare Provider Details

I. General information

NPI: 1487033650
Provider Name (Legal Business Name): PEARL DIANA MWANSA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: PEARL DIANA BEKALO

II. Dates (important events)

Enumeration Date: 05/21/2015
Last Update Date: 10/09/2024
Certification Date: 10/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2606 HOSPITAL BLVD STE B
CORPUS CHRISTI TX
78405
US

IV. Provider business mailing address

2900 SAINT MICHAEL DR STE 401
TEXARKANA TX
75503-5211
US

V. Phone/Fax

Practice location:
  • Phone: 361-902-4789
  • Fax: 361-902-4588
Mailing address:
  • Phone: 903-614-5383
  • Fax: 903-614-5343

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberBP10054275
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberR3719
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: