Provider Demographics
NPI:1063611481
Name:EDORO, OKOSUN (MD)
Entity type:Individual
Prefix:DR
First Name:OKOSUN
Middle Name:
Last Name:EDORO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5700 W GENESEE ST STE 109
Mailing Address - Street 2:
Mailing Address - City:CAMILLUS
Mailing Address - State:NY
Mailing Address - Zip Code:13031-3226
Mailing Address - Country:US
Mailing Address - Phone:315-487-1573
Mailing Address - Fax:315-487-2418
Practice Address - Street 1:5700 W GENESEE ST STE 109
Practice Address - Street 2:
Practice Address - City:CAMILLUS
Practice Address - State:NY
Practice Address - Zip Code:13031-3226
Practice Address - Country:US
Practice Address - Phone:315-487-1573
Practice Address - Fax:315-487-2418
Is Sole Proprietor?:No
Enumeration Date:2007-07-16
Last Update Date:2023-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD11918207R00000X
NC2015-02505207R00000X
NY320247-01207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine