Healthcare Provider Details

I. General information

NPI: 1336347764
Provider Name (Legal Business Name): VINCENT OGOCHUKWU OKPALA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2007
Last Update Date: 06/07/2023
Certification Date: 06/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 15T ST.
AUGUSTA GA
30912
US

IV. Provider business mailing address

1120 15T ST.
AUGUSTA GA
30912
US

V. Phone/Fax

Practice location:
  • Phone: 706-721-3052
  • Fax:
Mailing address:
  • Phone: 706-721-3052
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207PP0204X
TaxonomyPediatric Emergency Medicine (Emergency Medicine) Physician
License Number002436
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberN3956
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: