Provider Demographics
NPI:1851380273
Name:OKOYE, SAMUEL CHINWUBA (MD)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:CHINWUBA
Last Name:OKOYE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:SAMUEL
Other - Middle Name:CHINWUBA
Other - Last Name:OKOYE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:300 MONTEREY DR
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MS
Mailing Address - Zip Code:39056-5736
Mailing Address - Country:US
Mailing Address - Phone:601-914-0163
Mailing Address - Fax:601-914-0170
Practice Address - Street 1:5429 ROBINSON ROAD EXT
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39204-4138
Practice Address - Country:US
Practice Address - Phone:601-914-0163
Practice Address - Fax:601-914-0170
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-18
Last Update Date:2010-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS13321207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00116178Medicaid
MS080088556Medicare PIN
MSCC2133Medicare Oscar/Certification
MS00116178Medicaid
MS251936Medicare Oscar/Certification
MSF40271Medicare UPIN
MS080002536Medicare PIN
MS251850Medicare Oscar/Certification