Healthcare Provider Details

I. General information

NPI: 1265631907
Provider Name (Legal Business Name): IKECHUKWU OKORIE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2007
Last Update Date: 06/23/2023
Certification Date: 06/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3700 HARDY ST STE 10
HATTIESBURG MS
39402-1614
US

IV. Provider business mailing address

3700 HARDY ST STE 10
HATTIESBURG MS
39402-1614
US

V. Phone/Fax

Practice location:
  • Phone: 601-544-7212
  • Fax: 601-544-7013
Mailing address:
  • Phone: 601-544-7212
  • Fax: 601-544-7013

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number19875
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: