Healthcare Provider Details

I. General information

NPI: 1629193321
Provider Name (Legal Business Name): PAUL CHIKE OKOLOCHA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/20/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2054 GRANT ST
GARY IN
46404-3060
US

IV. Provider business mailing address

1314 FITZGERALD DR
MUNSTER IN
46321-4204
US

V. Phone/Fax

Practice location:
  • Phone: 219-949-7540
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number01041856
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: