Healthcare Provider Details

I. General information

NPI: 1578317335
Provider Name (Legal Business Name): ABRAHAM OKOROR MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/16/2024
Last Update Date: 05/21/2024
Certification Date: 05/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 UPPER RIVERDALE ROAD
RIVERDALE GA
30274
US

IV. Provider business mailing address

3803 OBSIDIAN DR
CHAMPAIGN IL
61822-4211
US

V. Phone/Fax

Practice location:
  • Phone: 770-991-8026
  • Fax:
Mailing address:
  • Phone: 217-729-2184
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number16385
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: