Provider Demographics
NPI:1356830491
Name:OKAFOR, TONY
Entity Type:Individual
Prefix:
First Name:TONY
Middle Name:
Last Name:OKAFOR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:247 GUNTOWN RD
Mailing Address - Street 2:
Mailing Address - City:ROGERSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37857-3926
Mailing Address - Country:US
Mailing Address - Phone:423-794-6307
Mailing Address - Fax:
Practice Address - Street 1:247 GUNTOWN RD
Practice Address - Street 2:
Practice Address - City:ROGERSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37857-3926
Practice Address - Country:US
Practice Address - Phone:423-794-6307
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-03
Last Update Date:2018-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN107234675344600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes344600000XTransportation ServicesTaxi
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN824900528Medicaid