Provider Demographics
NPI:1104871433
Name:OKOLO, JOSEPH M (MD)
Entity type:Individual
Prefix:
First Name:JOSEPH
Middle Name:M
Last Name:OKOLO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 400
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38302-0400
Mailing Address - Country:US
Mailing Address - Phone:731-423-8697
Mailing Address - Fax:731-422-5743
Practice Address - Street 1:700 W FOREST AVE
Practice Address - Street 2:STE 300
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38301-3937
Practice Address - Country:US
Practice Address - Phone:731-422-0330
Practice Address - Fax:731-422-0409
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2012-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN47713207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1524823Medicaid
TNP00973563Medicare PIN
TN103I061808Medicare PIN