Provider Demographics
NPI:1871825539
Name:RIVERS, MARVIN ODIE (BS)
Entity Type:Individual
Prefix:MR
First Name:MARVIN
Middle Name:ODIE
Last Name:RIVERS
Suffix:
Gender:M
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:808 NW 115TH ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73114-6900
Mailing Address - Country:US
Mailing Address - Phone:405-808-9105
Mailing Address - Fax:405-216-5272
Practice Address - Street 1:808 NW 115TH ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73114-6900
Practice Address - Country:US
Practice Address - Phone:405-808-9105
Practice Address - Fax:405-216-5272
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-05
Last Update Date:2010-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200123000AMedicaid