Provider Demographics
NPI:1417250143
Name:COBY, REVA GWENETTE
Entity Type:Individual
Prefix:MRS
First Name:REVA
Middle Name:GWENETTE
Last Name:COBY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2425 NE 10TH ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73117-5007
Mailing Address - Country:US
Mailing Address - Phone:405-424-2547
Mailing Address - Fax:
Practice Address - Street 1:2425 NE 10TH ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73117-5007
Practice Address - Country:US
Practice Address - Phone:405-424-2547
Practice Address - Fax:405-427-2662
Is Sole Proprietor?:No
Enumeration Date:2010-12-20
Last Update Date:2010-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK20684171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100729210Medicaid