Healthcare Provider Details

I. General information

NPI: 1295048528
Provider Name (Legal Business Name): BENJAMIN WOWO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2010
Last Update Date: 08/17/2022
Certification Date: 08/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

424 PARK GROVE LANE
KATY TX
77450-1571
US

IV. Provider business mailing address

3407 GRAND PEBBLE LN
KATY TX
77494-0707
US

V. Phone/Fax

Practice location:
  • Phone: 329-133-7651
  • Fax:
Mailing address:
  • Phone: 917-434-7735
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMD441257
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberP9770
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberP9770
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: