Provider Demographics
NPI:1629184098
Name:OKIE, THEODORE B
Entity Type:Individual
Prefix:
First Name:THEODORE
Middle Name:B
Last Name:OKIE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:THEODORE
Other - Middle Name:B
Other - Last Name:OKIE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:3510 MARTIN LUTHER KING JR BLVD
Mailing Address - Street 2:
Mailing Address - City:LYNWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90262-2010
Mailing Address - Country:US
Mailing Address - Phone:310-638-9391
Mailing Address - Fax:310-603-8749
Practice Address - Street 1:3510 MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:
Practice Address - City:LYNWOOD
Practice Address - State:CA
Practice Address - Zip Code:90262-2010
Practice Address - Country:US
Practice Address - Phone:310-638-9391
Practice Address - Fax:310-603-8749
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-21
Last Update Date:2010-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG8937207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG8937OtherCA LIC NUMBER
CA000G89370Medicaid
CAA58736Medicare UPIN
CAWG8937Medicare ID - Type Unspecified