Provider Demographics
NPI:1407831373
Name:BIVENS, MARILYN GRISHAM (MD)
Entity Type:Individual
Prefix:
First Name:MARILYN
Middle Name:GRISHAM
Last Name:BIVENS
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 1:104 CONTEMPO AVE
Mailing Address - Street 2:
Mailing Address - City:WEST MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71291-5312
Mailing Address - Country:US
Mailing Address - Phone:318-329-8181
Mailing Address - Fax:318-329-8183
Practice Address - Street 1:104 CONTEMPO AVE
Practice Address - Street 2:
Practice Address - City:WEST MONROE
Practice Address - State:LA
Practice Address - Zip Code:71291-5312
Practice Address - Country:US
Practice Address - Phone:318-329-8181
Practice Address - Fax:318-329-8183
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-13
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA12125R208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA12125ROtherMEDICAL LICENSE
LA1695611Medicaid
LA1695611Medicaid
LA12125ROtherMEDICAL LICENSE