Provider Demographics
NPI:1295772648
Name:OKONTA, SAMUEL (MD)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:
Last Name:OKONTA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21714 MERRICK BLVD
Mailing Address - Street 2:
Mailing Address - City:LAURELTON
Mailing Address - State:NY
Mailing Address - Zip Code:11413-1917
Mailing Address - Country:US
Mailing Address - Phone:718-712-1428
Mailing Address - Fax:718-712-1736
Practice Address - Street 1:21714 MERRICK BLVD
Practice Address - Street 2:
Practice Address - City:LAURELTON
Practice Address - State:NY
Practice Address - Zip Code:11413-1917
Practice Address - Country:US
Practice Address - Phone:718-712-1428
Practice Address - Fax:718-712-1736
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-01
Last Update Date:2016-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY177073207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY125951OtherBCBS
NY125951OtherBCBS
NY67H311Medicare ID - Type Unspecified