Healthcare Provider Details

I. General information

NPI: 1205575818
Provider Name (Legal Business Name): CHIMEZIE C OKOLOCHA DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2022
Last Update Date: 06/01/2022
Certification Date: 06/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4502 E 41ST ST
TULSA OK
74135-2536
US

IV. Provider business mailing address

335 W 9TH ST UNIT 801
INDIANAPOLIS IN
46202-3194
US

V. Phone/Fax

Practice location:
  • Phone: 918-660-3518
  • Fax:
Mailing address:
  • Phone: 219-789-6522
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: