Provider Demographics
NPI:1033371638
Name:OKONKWO, NNAEMEKA MICHAEL
Entity Type:Individual
Prefix:MR
First Name:NNAEMEKA
Middle Name:MICHAEL
Last Name:OKONKWO
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:MICHAEL
Other - Middle Name:N
Other - Last Name:OKONKWO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:6109 S WESTERN AVE STE 201
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90047-1454
Mailing Address - Country:US
Mailing Address - Phone:323-752-0746
Mailing Address - Fax:323-752-0834
Practice Address - Street 1:6109 S WESTERN AVE STE 201
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90047-1454
Practice Address - Country:US
Practice Address - Phone:323-752-0746
Practice Address - Fax:323-752-0834
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-26
Last Update Date:2008-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA103060332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
5077100001Medicare NSC