Healthcare Provider Details

I. General information

NPI: 1740035732
Provider Name (Legal Business Name): KENNETH KENECHUKWU OKONKWO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/22/2024
Last Update Date: 04/22/2024
Certification Date: 04/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

640 S. STATE STREET
DOVER DE
19901-3007
US

IV. Provider business mailing address

640 S. STATE STREET
DOVER DE
19901-3007
US

V. Phone/Fax

Practice location:
  • Phone: 302-744-6999
  • Fax:
Mailing address:
  • Phone: 302-744-6999
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberC7-0018508
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: