Provider Demographics
NPI:1972645695
Name:OKIRI, MARTIN KING
Entity Type:Individual
Prefix:MR
First Name:MARTIN
Middle Name:KING
Last Name:OKIRI
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:PO BOX 1311
Mailing Address - Street 2:
Mailing Address - City:BAYARD
Mailing Address - State:NM
Mailing Address - Zip Code:88023-1311
Mailing Address - Country:US
Mailing Address - Phone:505-590-4774
Mailing Address - Fax:505-388-1749
Practice Address - Street 1:220 S CORBIN
Practice Address - Street 2:
Practice Address - City:SILVER CITY
Practice Address - State:NM
Practice Address - Zip Code:88061
Practice Address - Country:US
Practice Address - Phone:505-590-4774
Practice Address - Fax:505-388-1749
Is Sole Proprietor?:No
Enumeration Date:2007-02-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0079181101YP2500X
NM271997103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Not Answered103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM0000023Medicaid
NM61509337Medicaid