MEDICARE: FIDELIS AJOBOME OKOTIE 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	207R00000X	Internal Medicine Physician	N8962	TX
2	208M00000X	Hospitalist Physician	0434428	KS
3	208M00000X	Hospitalist Physician	N8962	TX
4	207R00000X	Internal Medicine Physician	MD.207776	LA
5	208M00000X	Hospitalist Physician	MD.207776	LA
6	207R00000X	Internal Medicine Physician	70415	WI
7	208M00000X	Hospitalist Physician	2015-00495	NC
8	207R00000X	Internal Medicine Physician	38814	SC
9	207R00000X	Internal Medicine Physician	2015-00495	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1376856039
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	FIDELIS AJOBOME OKOTIE MD

Provider Business Mailing Address
First Line	:	PO BOX 743070
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30374-3070
Country	:	US
Telephone Number	:	864-560-4304
Fax Number	:	864-560-4413

Provider Business Practice Location Address
First Line	:	2555 JIMMY JOHNSON BOULEVARD
Second Line	:
City	:	PORT ARTHUR
State	:	TX
Zip	:	77640-2007
Country	:	US
Telephone Number	:	409-853-5086
Fax Number	:	409-853-5084

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

Provider Enumeration Date	:	07/22/2010
Last Update Date	:	01/30/2026

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