Basic Information
| Provider Information | |||||||||
| NPI: | 1184630212 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | OKELLEY | ||||||||
| FirstName: | EDWARD | ||||||||
| MiddleName: | TIMOTHY | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1326 | ||||||||
| Address2: | |||||||||
| City: | MARSHALL | ||||||||
| State: | TX | ||||||||
| PostalCode: | 756711326 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9039273782 | ||||||||
| FaxNumber: | 9039271764 | ||||||||
| Practice Location | |||||||||
| Address1: | 1011 SOUTH WILLIAM | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 755513245 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9037962868 | ||||||||
| FaxNumber: | 9037960826 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/31/2006 | ||||||||
| LastUpdateDate: | 07/07/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | G3658 | TX | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 133940003 | 05 | TX | MEDICAID | A007 | 01 | CHAMPUS | OTHER | 806058 | 01 | TX | BCBS | OTHER | 118097 | 01 | CHIPS | OTHER | 97279 | 01 | TX | BCBS | OTHER | 010017871 | 01 | MEDICARE RR | OTHER |