MEDICARE: SAMUEL OKONTA MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207P00000X	Emergency Medicine Physician	177073	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	125951	OTHER	NY	BCBS

General Provider Information

NPI Number	:	1295772648
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SAMUEL OKONTA MD

Provider Business Mailing Address
First Line	:	21714 MERRICK BLVD
Second Line	:
City	:	LAURELTON
State	:	NY
Zip	:	11413-1917
Country	:	US
Telephone Number	:	718-712-1428
Fax Number	:	718-712-1736

Provider Business Practice Location Address
First Line	:	21714 MERRICK BLVD
Second Line	:
City	:	LAURELTON
State	:	NY
Zip	:	11413-1917
Country	:	US
Telephone Number	:	718-712-1428
Fax Number	:	718-712-1736

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/01/2006
Last Update Date	:	09/08/2016

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