Provider Demographics
NPI:1114090248
Name:RATHGEBER, MARK EDWIN (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:EDWIN
Last Name:RATHGEBER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:701 MARKET DR
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73114
Mailing Address - Country:US
Mailing Address - Phone:405-951-3719
Mailing Address - Fax:405-951-3916
Practice Address - Street 1:701 MARKET DR
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73114
Practice Address - Country:US
Practice Address - Phone:405-951-3719
Practice Address - Fax:405-951-3916
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2014-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK162292084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100200890AMedicaid
OK100200890AMedicaid