Provider Demographics
NPI:1598407793
Name:OKEZUE, CHISOM DOMINIC
Entity type:Individual
Prefix:
First Name:CHISOM
Middle Name:DOMINIC
Last Name:OKEZUE
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 1:11043 173RD ST
Mailing Address - Street 2:
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11433-3438
Mailing Address - Country:US
Mailing Address - Phone:347-229-6353
Mailing Address - Fax:
Practice Address - Street 1:12 N 7TH AVE
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:NY
Practice Address - Zip Code:10550-2026
Practice Address - Country:US
Practice Address - Phone:914-664-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-08
Last Update Date:2025-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY339600207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine