Healthcare Provider Details

I. General information

NPI: 1134235369
Provider Name (Legal Business Name): CORNELIUS S OKONKWO DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/21/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2101 W FRANKLIN BLVD
GASTONIA NC
28052-1338
US

IV. Provider business mailing address

2101 W FRANKLIN BLVD
GASTONIA NC
28052-1338
US

V. Phone/Fax

Practice location:
  • Phone: 704-867-8855
  • Fax: 704-867-1414
Mailing address:
  • Phone: 704-867-8855
  • Fax: 704-867-1414

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: