Healthcare Provider Details

I. General information

NPI: 1528358652
Provider Name (Legal Business Name): EWAEN OSAMUYI OKAO M.D,
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2011
Last Update Date: 08/14/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13 N HARTFORD AVE ATLANTICARE BEHAVIORAL HEALTH
ATLANTIC CITY NJ
08401-3512
US

IV. Provider business mailing address

661 SHREWSBURY AVE
SHREWSBURY NJ
07702-4183
US

V. Phone/Fax

Practice location:
  • Phone: 609-348-1161
  • Fax:
Mailing address:
  • Phone: 732-345-3400
  • Fax: 732-345-3104

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number25MA09235300
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMD442395
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number25MA09235300
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: