Healthcare Provider Details

I. General information

NPI: 1255385985
Provider Name (Legal Business Name): SANDE O OKELO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2006
Last Update Date: 11/16/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10833 LE CONTE AVE 12-311 MDCC
LOS ANGELES CA
90095-3075
US

IV. Provider business mailing address

10833 LE CONTE AVE 32-263 CHS
LOS ANGELES CA
90095-3075
US

V. Phone/Fax

Practice location:
  • Phone: 310-267-0606
  • Fax:
Mailing address:
  • Phone: 310-267-0606
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080P0214X
TaxonomyPediatric Pulmonology Physician
License NumberD56975
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code2080P0214X
TaxonomyPediatric Pulmonology Physician
License NumberA68246
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: