Provider Demographics
NPI:1043280563
Name:OKORO, BONAVENTURE C (MD)
Entity Type:Individual
Prefix:
First Name:BONAVENTURE
Middle Name:C
Last Name:OKORO
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 1:36115 SCHOOLCRAFT RD
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48150-1216
Mailing Address - Country:US
Mailing Address - Phone:734-464-0887
Mailing Address - Fax:734-402-0254
Practice Address - Street 1:5542 AIRPORT HWY
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43615-7304
Practice Address - Country:US
Practice Address - Phone:734-464-0887
Practice Address - Fax:734-402-0254
Is Sole Proprietor?:No
Enumeration Date:2006-01-26
Last Update Date:2014-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-07-1648-O207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH5619197341A13OtherBLUECROSS BLUESHIELD
OH2008482Medicaid
OH0824987OtherMCR (AUC)
G52212Medicare UPIN
OH5619197341A13OtherBLUECROSS BLUESHIELD