Healthcare Provider Details

I. General information

NPI: 1447270004
Provider Name (Legal Business Name): BENJAMIN OKONTA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2006
Last Update Date: 10/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 MONTAUK HWY
WEST ISLIP NY
11795-4927
US

IV. Provider business mailing address

245 OLD COUNTRY RD
MELVILLE NY
11747-2726
US

V. Phone/Fax

Practice location:
  • Phone: 631-376-3610
  • Fax: 631-376-3635
Mailing address:
  • Phone: 631-465-6141
  • Fax: 631-465-1967

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number200249-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: