=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851509145
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | UZOMA BEN GBULIE MBBS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/18/2007
-----------------------------------------------------
Last Update Date | 11/05/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1021 MATLOCK RD STE 103
-----------------------------------------------------
City | MANSFIELD
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76063-3443
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 682-400-2152
-----------------------------------------------------
Fax | 817-377-6568
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 961205
-----------------------------------------------------
City | FORT WORTH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76161-0205
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-740-8450
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number | R3677
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2086S0122X
-----------------------------------------------------
Taxonomy Name | Plastic and Reconstructive Surgery Physician
-----------------------------------------------------
License Number | R3677
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------