Provider Demographics
NPI:1710612478
Name:COKLOW, MARVIN
Entity Type:Individual
Prefix:
First Name:MARVIN
Middle Name:
Last Name:COKLOW
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 1:5030 N MARINE DR
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-3267
Mailing Address - Country:US
Mailing Address - Phone:773-597-7698
Mailing Address - Fax:
Practice Address - Street 1:5030 N MARINE DR
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-3267
Practice Address - Country:US
Practice Address - Phone:773-597-7698
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-18
Last Update Date:2022-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service