Healthcare Provider Details

I. General information

NPI: 1154876571
Provider Name (Legal Business Name): CHARLES OBUM OKOYE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2016
Last Update Date: 08/16/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11942 179TH ST
JAMAICA NY
11434-1942
US

IV. Provider business mailing address

11942 179TH ST
JAMAICA NY
11434-1942
US

V. Phone/Fax

Practice location:
  • Phone: 646-379-7550
  • Fax:
Mailing address:
  • Phone: 646-379-7550
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number717566
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: