Provider Demographics
NPI:1205179454
Name:MARCUM, KEVIN PAUL
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:PAUL
Last Name:MARCUM
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 1:23106 SW BISHOP RD
Mailing Address - Street 2:
Mailing Address - City:INDIAHOMA
Mailing Address - State:OK
Mailing Address - Zip Code:73552
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:23106 SW BISHOP RD
Practice Address - Street 2:
Practice Address - City:INDIAHOMA
Practice Address - State:OK
Practice Address - Zip Code:73552
Practice Address - Country:US
Practice Address - Phone:580-284-4219
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-05
Last Update Date:2013-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor