Basic Information
| Provider Information | |||||||||
| NPI: | 1053340869 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | OKONKWO | ||||||||
| FirstName: | NDUBUEZE | ||||||||
| MiddleName: | FIDELIS | ||||||||
| NamePrefix: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 720 W CENTRAL AVE | ||||||||
| Address2: | |||||||||
| City: | EL DORADO | ||||||||
| State: | KS | ||||||||
| PostalCode: | 670422112 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3163213300 | ||||||||
| FaxNumber: | 3163212916 | ||||||||
| Practice Location | |||||||||
| Address1: | 720 W CENTRAL AVE | ||||||||
| Address2: | |||||||||
| City: | EL DORADO | ||||||||
| State: | KS | ||||||||
| PostalCode: | 670422112 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3163213300 | ||||||||
| FaxNumber: | 3163212916 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/02/2006 | ||||||||
| LastUpdateDate: | 10/19/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 07/17/2007 | ||||||||
| NPIReactivationDate: | 06/16/2008 | ||||||||
| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 04-39127 | KS | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | PENDING | 05 | KS | MEDICAID |