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General NPI Number Information
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NPI Number | 1710612478
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Entity Type | Individual
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Provider Name | MARVIN COKLOW
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Gender | Male
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Dates
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Enumeration Date | 07/18/2022
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Last Update Date | 07/18/2022
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Provider Practice Location Address
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Address Line | 5030 N MARINE DR
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City | CHICAGO
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State | IL
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Zip | 60640-3267
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Country | US
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Telephone | 773-597-7698
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Fax |
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Provider Business Mailing Address
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Address Line | 5030 N MARINE DR
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City | CHICAGO
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State | IL
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Zip | 60640-3267
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Country | US
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Telephone | 773-597-7698
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 305S00000X
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Taxonomy Name | Point of Service
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License Number |
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License Number State |
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