Provider Demographics
NPI:1811180664
Name:MOUL, MARVIN
Entity type:Individual
Prefix:
First Name:MARVIN
Middle Name:
Last Name:MOUL
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 1:104 LONE OAK CIRCLE
Mailing Address - Street 2:
Mailing Address - City:FORT GIBSON
Mailing Address - State:OK
Mailing Address - Zip Code:74434
Mailing Address - Country:US
Mailing Address - Phone:918-478-2101
Mailing Address - Fax:
Practice Address - Street 1:104 LONE OAK CIR
Practice Address - Street 2:
Practice Address - City:FORT GIBSON
Practice Address - State:OK
Practice Address - Zip Code:74434-5001
Practice Address - Country:US
Practice Address - Phone:918-478-2101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-24
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK5887207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine