Provider Demographics
NPI:1104364041
Name:VERA, MARCUS ANGELO
Entity Type:Individual
Prefix:
First Name:MARCUS
Middle Name:ANGELO
Last Name:VERA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4400 N LINCOLN BLVD
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73105-5108
Mailing Address - Country:US
Mailing Address - Phone:405-425-0428
Mailing Address - Fax:405-419-3042
Practice Address - Street 1:4202 SW LEE BLVD BLDG B
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73505-8300
Practice Address - Country:US
Practice Address - Phone:580-771-2662
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-10
Last Update Date:2021-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
OK1344106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No171M00000XOther Service ProvidersCase Manager/Care Coordinator