Provider Demographics
NPI:1023031861
Name:COUCH, MARVIN WAYNE II (MD)
Entity type:Individual
Prefix:DR
First Name:MARVIN
Middle Name:WAYNE
Last Name:COUCH
Suffix:II
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:514 E GRAND AVE # 273
Mailing Address - Street 2:
Mailing Address - City:LARAMIE
Mailing Address - State:WY
Mailing Address - Zip Code:82070-3839
Mailing Address - Country:US
Mailing Address - Phone:307-314-3330
Mailing Address - Fax:307-324-9025
Practice Address - Street 1:542 16TH ST
Practice Address - Street 2:
Practice Address - City:RAWLINS
Practice Address - State:WY
Practice Address - Zip Code:82301-5241
Practice Address - Country:US
Practice Address - Phone:307-324-2750
Practice Address - Fax:307-324-2759
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2021-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY5629A207V00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
304114Medicare ID - Type Unspecified
WYG23176Medicare UPIN