Provider Demographics
NPI:1528372729
Name:OKOLO, EKENE IFEANYI
Entity Type:Individual
Prefix:DR
First Name:EKENE
Middle Name:IFEANYI
Last Name:OKOLO
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:PO BOX 26726
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78755-0726
Mailing Address - Country:US
Mailing Address - Phone:512-407-8686
Mailing Address - Fax:512-406-6216
Practice Address - Street 1:300 UNIVERSITY BLVD
Practice Address - Street 2:
Practice Address - City:ROUND ROCK
Practice Address - State:TX
Practice Address - Zip Code:78665-1032
Practice Address - Country:US
Practice Address - Phone:512-509-0100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-29
Last Update Date:2024-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN5920207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX217717203Medicaid
TX217717205Medicaid
TX217717202Medicaid
TX217717204Medicaid
TXTXB162297Medicare PIN
TXTXB162336Medicare PIN
TX217717205Medicaid
TXTXB162291Medicare PIN
TXTXB162333Medicare PIN