Provider Demographics
NPI:1134235369
Name:OKONKWO, CORNELIUS S (DO)
Entity type:Individual
Prefix:
First Name:CORNELIUS
Middle Name:S
Last Name:OKONKWO
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2101 W FRANKLIN BLVD
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28052-1338
Mailing Address - Country:US
Mailing Address - Phone:704-867-8855
Mailing Address - Fax:704-867-1414
Practice Address - Street 1:2101 W FRANKLIN BLVD
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28052-1338
Practice Address - Country:US
Practice Address - Phone:704-867-8855
Practice Address - Fax:704-867-1414
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-21
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89129N7Medicaid
NC89129N7Medicaid
NCH47867Medicare UPIN