Healthcare Provider Details

I. General information

NPI: 1104871433
Provider Name (Legal Business Name): JOSEPH M OKOLO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2006
Last Update Date: 11/29/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 W FOREST AVE STE 300
JACKSON TN
38301-3937
US

IV. Provider business mailing address

PO BOX 400
JACKSON TN
38302-0400
US

V. Phone/Fax

Practice location:
  • Phone: 731-422-0330
  • Fax: 731-422-0409
Mailing address:
  • Phone: 731-423-8697
  • Fax: 731-422-5743

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number47713
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number47713
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: