Provider Demographics
NPI:1487613840
Name:OKWARA, BENEDICT O (MD)
Entity type:Individual
Prefix:DR
First Name:BENEDICT
Middle Name:O
Last Name:OKWARA
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 1:404 SOUTH SUTHERLAND AVE.
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:NC
Mailing Address - Zip Code:28112-5060
Mailing Address - Country:US
Mailing Address - Phone:704-291-9267
Mailing Address - Fax:704-283-7939
Practice Address - Street 1:404 SOUTH SUTHERLAND AVE.
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:NC
Practice Address - Zip Code:28112
Practice Address - Country:US
Practice Address - Phone:704-291-9267
Practice Address - Fax:704-283-7939
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-22
Last Update Date:2018-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC33878207RA0000X, 208000000X, 2080A0000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RA0000XAllopathic & Osteopathic PhysiciansInternal MedicineAdolescent Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCN33878Medicaid
NC7963995Medicaid
SCN33878Medicaid
NC2159649GMedicare PIN