Healthcare Provider Details

I. General information

NPI: 1528222312
Provider Name (Legal Business Name): KINGSTON OKRAH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2008
Last Update Date: 12/08/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2700 W 9TH AVE STE. 310
OSHKOSH WI
54904-7247
US

IV. Provider business mailing address

2700 W 9TH AVE STE. 310
OSHKOSH WI
54904-7247
US

V. Phone/Fax

Practice location:
  • Phone: 920-223-3550
  • Fax:
Mailing address:
  • Phone: 920-223-3550
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number63918
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number63918-20
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number37942
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: