Basic Information
| Provider Information | |||||||||
| NPI: | 1922394030 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | OKOLI | ||||||||
| FirstName: | EMEKA | ||||||||
| MiddleName: | JUDE | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2627 RIVERSIDE AVE | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322044712 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043087372 | ||||||||
| FaxNumber: | 9043082908 | ||||||||
| Practice Location | |||||||||
| Address1: | 2627 RIVERSIDE AVE | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322044712 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043087372 | ||||||||
| FaxNumber: | 9043082908 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2011 | ||||||||
| LastUpdateDate: | 12/30/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | TRN 16686 | FL | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | ME120789 | FL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 013228500 | 05 | FL | MEDICAID |