Healthcare Provider Details

I. General information

NPI: 1376039180
Provider Name (Legal Business Name): VICTOR C EZEMBA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/04/2018
Last Update Date: 07/04/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6922 ADDICKS CLODINE RD
HOUSTON TX
77083-1102
US

IV. Provider business mailing address

6922 ADDICKS CLODINE RD
HOUSTON TX
77083-1102
US

V. Phone/Fax

Practice location:
  • Phone: 713-922-7303
  • Fax: 832-295-3800
Mailing address:
  • Phone: 713-922-7303
  • Fax: 832-295-3800

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2471C3401X
TaxonomyComputed Tomography Radiologic Technologist
License Number15551
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: