Healthcare Provider Details

I. General information

NPI: 1023031861
Provider Name (Legal Business Name): MARVIN WAYNE COUCH II M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2006
Last Update Date: 09/28/2021
Certification Date: 09/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

542 16TH ST
RAWLINS WY
82301-5241
US

IV. Provider business mailing address

514 E GRAND AVE # 273
LARAMIE WY
82070-3839
US

V. Phone/Fax

Practice location:
  • Phone: 307-324-2750
  • Fax: 307-324-2759
Mailing address:
  • Phone: 307-314-3330
  • Fax: 307-324-9025

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number5629A
License Number StateWY
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number5629A
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: