Provider Demographics
NPI:1376856039
Name:OKOTIE, FIDELIS AJOBOME (MD)
Entity Type:Individual
Prefix:
First Name:FIDELIS
Middle Name:AJOBOME
Last Name:OKOTIE
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 1:4299 SAN FELIPE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77027-2916
Mailing Address - Country:US
Mailing Address - Phone:832-476-3900
Mailing Address - Fax:832-476-6494
Practice Address - Street 1:2555 JIMMY JOHNSON BOULEVARD
Practice Address - Street 2:
Practice Address - City:PORT ARTHUR
Practice Address - State:TX
Practice Address - Zip Code:77640-2007
Practice Address - Country:US
Practice Address - Phone:409-853-5086
Practice Address - Fax:409-853-5084
Is Sole Proprietor?:No
Enumeration Date:2010-07-22
Last Update Date:2023-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN8962207R00000X, 208M00000X
NC2015-00495207R00000X, 208M00000X
SCMD38814207R00000X
LAMD.207776207R00000X, 208M00000X
KS0434428208M00000X
WI70415207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100136014Medicaid