1629302112 NPI number — PREVENTIVE MEDICINE ASSOCIATES

Table of content: MICHAEL C. OKIMURA MD (NPI 1861570533)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629302112 NPI number — PREVENTIVE MEDICINE ASSOCIATES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PREVENTIVE MEDICINE ASSOCIATES
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1629302112
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/30/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1208B VFW PKWY
Provider Second Line Business Mailing Address:
SUITE 305
Provider Business Mailing Address City Name:
WEST ROXBURY
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02132-4349
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
617-477-8294
Provider Business Mailing Address Fax Number:
617-477-8294

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1208B VFW PKWY
Provider Second Line Business Practice Location Address:
SUITE 305
Provider Business Practice Location Address City Name:
WEST ROXBURY
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02132-4349
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
617-477-8294
Provider Business Practice Location Address Fax Number:
617-477-8294
Provider Enumeration Date:
09/30/2009

Additional Information

Authorized Official

Authorized Official Last Name:
DELONG
Authorized Official First Name:
MARY
Authorized Official Middle Name:
J
Authorized Official Title or Position:
CREDENTIALING MANAGER
Authorized Official Telephone Number:
413-222-7711

Provider Taxonomy Codes

  • Taxonomy code: 207QA0401X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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