Provider Demographics
NPI:1619326956
Name:OKOROCHA, BERTRAM
Entity Type:Individual
Prefix:
First Name:BERTRAM
Middle Name:
Last Name:OKOROCHA
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 1:1037 DEERPASS DR
Mailing Address - Street 2:
Mailing Address - City:CHANNELVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:77530-3365
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1037 DEERPASS DR
Practice Address - Street 2:
Practice Address - City:CHANNELVIEW
Practice Address - State:TX
Practice Address - Zip Code:77530-3365
Practice Address - Country:US
Practice Address - Phone:281-318-8644
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-07
Last Update Date:2020-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX233073164X00000X
TX964293163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No164X00000XNursing Service ProvidersLicensed Vocational Nurse