Provider Demographics
NPI:1538151063
Name:OKAWA, ALLISYN (MD)
Entity type:Individual
Prefix:
First Name:ALLISYN
Middle Name:
Last Name:OKAWA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4650 HARRISON BLVD
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84403-4303
Mailing Address - Country:US
Mailing Address - Phone:801-475-3000
Mailing Address - Fax:801-475-3414
Practice Address - Street 1:4700 HARRISON BLVD
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-4303
Practice Address - Country:US
Practice Address - Phone:801-475-3000
Practice Address - Fax:801-475-3001
Is Sole Proprietor?:No
Enumeration Date:2005-08-19
Last Update Date:2012-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT296278-12052086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
G11725Medicare UPIN
005587304Medicare ID - Type Unspecified
000055873Medicare ID - Type Unspecified