Healthcare Provider Details

I. General information

NPI: 1457595258
Provider Name (Legal Business Name): BENJAMIN ISAAC MWANIKA DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/23/2009
Last Update Date: 09/26/2022
Certification Date: 09/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2509 PLEASANT RUN DR
HARRISONBURG VA
22801-8720
US

IV. Provider business mailing address

11511 SHADOW CREEK PKWY
PEARLAND TX
77584-7298
US

V. Phone/Fax

Practice location:
  • Phone: 540-689-5500
  • Fax: 540-757-7574
Mailing address:
  • Phone: 713-442-0000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberT9755
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number0102203559
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberT9755
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: