Provider Demographics
NPI:1639797418
Name:OKEREKE, IKECHUKWU
Entity Type:Individual
Prefix:
First Name:IKECHUKWU
Middle Name:
Last Name:OKEREKE
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 1:529 BEACH 20TH ST
Mailing Address - Street 2:
Mailing Address - City:FAR ROCKAWAY
Mailing Address - State:NY
Mailing Address - Zip Code:11691-3615
Mailing Address - Country:US
Mailing Address - Phone:718-327-7307
Mailing Address - Fax:718-327-3294
Practice Address - Street 1:1 BAY AVENUE
Practice Address - Street 2:
Practice Address - City:MONTCLAIR
Practice Address - State:NJ
Practice Address - Zip Code:07042-2033
Practice Address - Country:US
Practice Address - Phone:973-429-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-08
Last Update Date:2023-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY105709-01207R00000X
NYP105709207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine