Provider Demographics
NPI:1023090610
Name:RODGERS, MARVIN DALE (DO)
Entity type:Individual
Prefix:DR
First Name:MARVIN
Middle Name:DALE
Last Name:RODGERS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 SW 89TH ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73139-8514
Mailing Address - Country:US
Mailing Address - Phone:405-631-1116
Mailing Address - Fax:405-631-1825
Practice Address - Street 1:210 SW 89TH ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73139-8514
Practice Address - Country:US
Practice Address - Phone:405-631-1116
Practice Address - Fax:405-631-1825
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-18
Last Update Date:2010-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2192207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK731334611OtherUS TAX ID NUMBER
OKE09702Medicare UPIN