Provider Demographics
NPI:1215115704
Name:CHARLES I OKONKWO MD INC
Entity type:Organization
Organization Name:CHARLES I OKONKWO MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:IFEANYI
Authorized Official - Last Name:OKONKWO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:323-234-7200
Mailing Address - Street 1:231 W VERNON AVE
Mailing Address - Street 2:SUITE 105
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90037-2700
Mailing Address - Country:US
Mailing Address - Phone:323-234-7200
Mailing Address - Fax:
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-06
Last Update Date:2011-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA31084207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW5103BOtherMEDICARE GROUP
CA00A310840Medicaid
CAA87502Medicare UPIN
CAW5103BOtherMEDICARE GROUP