Provider Demographics
NPI:1760094791
Name:OKAILI, GIDEON
Entity Type:Individual
Prefix:
First Name:GIDEON
Middle Name:
Last Name:OKAILI
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 1:2051 W CUMBERLAND RD APT 917
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75703-7856
Mailing Address - Country:US
Mailing Address - Phone:832-364-1107
Mailing Address - Fax:
Practice Address - Street 1:2900 S LOOP 256
Practice Address - Street 2:
Practice Address - City:PALESTINE
Practice Address - State:TX
Practice Address - Zip Code:75801-6958
Practice Address - Country:US
Practice Address - Phone:903-731-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-20
Last Update Date:2020-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX66795183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist