Healthcare Provider Details

I. General information

NPI: 1578856217
Provider Name (Legal Business Name): GOROH OKAZAKI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2011
Last Update Date: 01/19/2022
Certification Date: 01/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4190 E WOODMEN RD STE 100
COLORADO SPRINGS CO
80920-8075
US

IV. Provider business mailing address

4190 E WOODMEN RD STE 100
COLORADO SPRINGS CO
80920-8075
US

V. Phone/Fax

Practice location:
  • Phone: 719-722-2542
  • Fax:
Mailing address:
  • Phone: 719-722-2542
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number39317
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberDR.0067322
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: