Provider Demographics
NPI:1063550234
Name:OKONKWO, CHARLES I (MD)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:I
Last Name:OKONKWO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:CHARLES
Other - Middle Name:I
Other - Last Name:OKONKWO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 260145
Mailing Address - Street 2:
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91426-0145
Mailing Address - Country:US
Mailing Address - Phone:323-234-7200
Mailing Address - Fax:323-234-1922
Practice Address - Street 1:231 W VERNON AVE
Practice Address - Street 2:SUITE 105
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90037-2700
Practice Address - Country:US
Practice Address - Phone:323-234-7200
Practice Address - Fax:323-234-1922
Is Sole Proprietor?:No
Enumeration Date:2007-02-01
Last Update Date:2011-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA31084207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A310840Medicaid
CA00A310840Medicaid
CAWA31084CMedicare PIN
CAW5103BMedicare PIN
CAHA31084AMedicare PIN