Provider Demographics
NPI:1821023110
Name:OKOLO, PETUA A (DO)
Entity Type:Individual
Prefix:
First Name:PETUA
Middle Name:A
Last Name:OKOLO
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2207 MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76013-5916
Mailing Address - Country:US
Mailing Address - Phone:817-465-7400
Mailing Address - Fax:817-465-7402
Practice Address - Street 1:2207 MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76013-5916
Practice Address - Country:US
Practice Address - Phone:817-465-7400
Practice Address - Fax:817-465-7402
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2013-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM0846207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX174464101Medicaid
TX174464102Medicaid
TX8D6819Medicare ID - Type Unspecified
TX174464101Medicaid
TX174464102Medicaid