Healthcare Provider Details

I. General information

NPI: 1972604817
Provider Name (Legal Business Name): SAMUEL IFEANYI OKOROZO PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

82-68 164TH ST
JAMAICA NY
11432-1121
US

IV. Provider business mailing address

79-01 BROADWAY MANAGED CARE, D1-01
ELMHURST NY
11373-1329
US

V. Phone/Fax

Practice location:
  • Phone: 718-883-3225
  • Fax: 718-883-6193
Mailing address:
  • Phone: 718-334-1921
  • Fax: 718-334-3432

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number004910
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: