Provider Demographics
NPI:1174615165
Name:OKOYA, JACKSON A (MD)
Entity type:Individual
Prefix:
First Name:JACKSON
Middle Name:A
Last Name:OKOYA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 ASTOR PL
Mailing Address - Street 2:
Mailing Address - City:AVENEL
Mailing Address - State:NJ
Mailing Address - Zip Code:07001-1460
Mailing Address - Country:US
Mailing Address - Phone:973-416-6981
Mailing Address - Fax:973-375-5766
Practice Address - Street 1:40 UNION AVE
Practice Address - Street 2:SUITE 204
Practice Address - City:IRVINGTON
Practice Address - State:NJ
Practice Address - Zip Code:07111-3277
Practice Address - Country:US
Practice Address - Phone:973-416-6981
Practice Address - Fax:973-375-5766
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA52181207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ3822109Medicaid
NJ555063Medicare ID - Type Unspecified
NJE13368Medicare UPIN