Healthcare Provider Details

I. General information

NPI: 1902851330
Provider Name (Legal Business Name): OKOLOCHA MEDICAL CORP.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/24/2006
Last Update Date: 08/22/2020
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: 219-949-7545
Mailing address:
  • Phone: 219-922-4802
  • 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: DR. PAUL CHIKE OKOLOCHA
Title or Position: PHYSICIAN
Credential: M.D.
Phone: 219-949-7540