Healthcare Provider Details

I. General information

NPI: 1295772648
Provider Name (Legal Business Name): SAMUEL OKONTA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/01/2006
Last Update Date: 09/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21714 MERRICK BLVD
LAURELTON NY
11413-1917
US

IV. Provider business mailing address

21714 MERRICK BLVD
LAURELTON NY
11413-1917
US

V. Phone/Fax

Practice location:
  • Phone: 718-712-1428
  • Fax: 718-712-1736
Mailing address:
  • Phone: 718-712-1428
  • Fax: 718-712-1736

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number177073
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: