Provider Demographics
NPI:1811473721
Name:OKYENIBA MEDICAL PC
Entity type:Organization
Organization Name:OKYENIBA MEDICAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:K
Authorized Official - Last Name:MENSAH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-295-8243
Mailing Address - Street 1:58 E KINGSBRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10468-7517
Mailing Address - Country:US
Mailing Address - Phone:718-295-8243
Mailing Address - Fax:718-584-3805
Practice Address - Street 1:58 EAST KINGSBRIDGE ROAD
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10468
Practice Address - Country:US
Practice Address - Phone:718-295-8243
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-13
Last Update Date:2018-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY144315208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY=========Medicaid