Healthcare Provider Details

I. General information

NPI: 1215553771
Provider Name (Legal Business Name): ICHIRO OKANO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2020
Last Update Date: 04/21/2021
Certification Date: 04/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

535 E 70TH ST
NEW YORK NY
10021-4898
US

IV. Provider business mailing address

525 E 72ND ST APT 16D
NEW YORK NY
10021-9606
US

V. Phone/Fax

Practice location:
  • Phone: 917-260-4524
  • Fax:
Mailing address:
  • Phone: 716-428-1757
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License Number107227-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: