Provider Demographics
NPI:1255385985
Name:OKELO, SANDE O (MD)
Entity type:Individual
Prefix:
First Name:SANDE
Middle Name:O
Last Name:OKELO
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 1:10833 LE CONTE AVE
Mailing Address - Street 2:32-263 CHS
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90095-3075
Mailing Address - Country:US
Mailing Address - Phone:310-267-0606
Mailing Address - Fax:
Practice Address - Street 1:10833 LE CONTE AVE
Practice Address - Street 2:12-311 MDCC
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90095-3075
Practice Address - Country:US
Practice Address - Phone:310-267-0606
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2011-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD569752080P0214X
CAA682462080P0214X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0214XAllopathic & Osteopathic PhysiciansPediatricsPediatric Pulmonology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD952101100Medicaid
MDKR44JHMedicare ID - Type UnspecifiedGROUP
MD952101100Medicaid
MD161348YTJMedicare PIN
CAW11810 GROUPMedicare PIN
MDH97232Medicare UPIN
MDH143Medicare ID - Type UnspecifiedINDIVIDUAL