Provider Demographics
NPI:1639149644
Name:MANEVITZ, REBECCA LEAH (MD)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:LEAH
Last Name:MANEVITZ
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 1:1 VALERO WAY
Mailing Address - Street 2:
Mailing Address - City:ARDMORE
Mailing Address - State:OK
Mailing Address - Zip Code:73401-1615
Mailing Address - Country:US
Mailing Address - Phone:580-221-6690
Mailing Address - Fax:210-479-2010
Practice Address - Street 1:1 VALERO WAY
Practice Address - Street 2:
Practice Address - City:ARDMORE
Practice Address - State:OK
Practice Address - Zip Code:73401-1615
Practice Address - Country:US
Practice Address - Phone:580-221-6690
Practice Address - Fax:210-479-2010
Is Sole Proprietor?:No
Enumeration Date:2006-01-23
Last Update Date:2021-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK13788207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100002210BMedicaid
OK246803201Medicare PIN
OKC95206Medicare UPIN