Healthcare Provider Details

I. General information

NPI: 1376517524
Provider Name (Legal Business Name): IGHO C OLOBIA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/15/2006
Last Update Date: 07/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

541 W MAIN ST STE 110
LEWISVILLE TX
75057
US

IV. Provider business mailing address

541 W MAIN ST STE 110
LEWISVILLE TX
75057-3628
US

V. Phone/Fax

Practice location:
  • Phone: 469-702-6633
  • Fax: 469-702-6636
Mailing address:
  • Phone: 469-702-6633
  • Fax: 469-702-6636

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberK4178
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: