Provider Demographics
NPI:1851594691
Name:OKOYE, OTUOME MANTU RA (PT)
Entity Type:Individual
Prefix:
First Name:OTUOME
Middle Name:MANTU RA
Last Name:OKOYE
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2011
Mailing Address - Street 2:
Mailing Address - City:WINDERMERE
Mailing Address - State:FL
Mailing Address - Zip Code:34786
Mailing Address - Country:US
Mailing Address - Phone:386-736-3108
Mailing Address - Fax:386-736-3643
Practice Address - Street 1:911 N SPRING GARDEN AVE
Practice Address - Street 2:
Practice Address - City:DELAND
Practice Address - State:FL
Practice Address - Zip Code:32720
Practice Address - Country:US
Practice Address - Phone:386-736-3108
Practice Address - Fax:386-736-3643
Is Sole Proprietor?:No
Enumeration Date:2007-06-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT11796225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY67382Medicare ID - Type Unspecified