Provider Demographics
NPI:1649702325
Name:OKROS, SELENE
Entity type:Individual
Prefix:
First Name:SELENE
Middle Name:
Last Name:OKROS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SELENE
Other - Middle Name:
Other - Last Name:GOMEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5 WILDWOOD DR APT 14D
Mailing Address - Street 2:
Mailing Address - City:WAPPINGERS FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:12590-2042
Mailing Address - Country:US
Mailing Address - Phone:914-475-6206
Mailing Address - Fax:
Practice Address - Street 1:5 WILDWOOD DR APT 14D
Practice Address - Street 2:
Practice Address - City:WAPPINGERS FALLS
Practice Address - State:NY
Practice Address - Zip Code:12590-2042
Practice Address - Country:US
Practice Address - Phone:914-475-6206
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-31
Last Update Date:2017-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYW39035PMedicaid
NY74333203600OtherFIDELIS