Healthcare Provider Details

I. General information

NPI: 1104897024
Provider Name (Legal Business Name): CHARLES N. OKOLO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/30/2006
Last Update Date: 01/05/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1151 CLEVELAND AVE SUITE D
EAST POINT GA
30344-3600
US

IV. Provider business mailing address

1151 CLEVELAND AVE SUITE D
EAST POINT GA
30344-3600
US

V. Phone/Fax

Practice location:
  • Phone: 404-761-7949
  • Fax: 404-761-7386
Mailing address:
  • Phone: 404-761-7949
  • Fax: 404-761-7386

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number048686
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: