MEDICARE: MARCUS DERRELL GOSS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103K00000X	Behavior Analyst

General Provider Information

NPI Number	:	1619255031
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARCUS DERRELL GOSS

Provider Business Mailing Address
First Line	:	12107 HERITAGE PARK RD
Second Line	:	136
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73120-9514
Country	:	US
Telephone Number	:	707-731-3357
Fax Number	:

Provider Business Practice Location Address
First Line	:	12107 HERITAGE PARK RD
Second Line	:	136
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73120-9514
Country	:	US
Telephone Number	:	707-731-3357
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/02/2011
Last Update Date	:	08/02/2011

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