Provider Demographics
NPI:1043696750
Name:OKPOMO, GODWIN SR (NP)
Entity Type:Individual
Prefix:MR
First Name:GODWIN
Middle Name:
Last Name:OKPOMO
Suffix:SR
Gender:M
Credentials:NP
Other - Prefix:DR
Other - First Name:KINGSLEY
Other - Middle Name:
Other - Last Name:NWOKEJI
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:2962 WICKHAM AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10469-3324
Mailing Address - Country:US
Mailing Address - Phone:646-384-0252
Mailing Address - Fax:
Practice Address - Street 1:2962 WICKHAM AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10469-3324
Practice Address - Country:US
Practice Address - Phone:646-384-0252
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-04
Last Update Date:2015-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF401152-1363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health