MEDICARE: CODY MARKS PTA

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	225200000X	Physical Therapy Assistant	7174	MS

General Provider Information

NPI Number	:	1922700822
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CODY MARKS PTA

Provider Business Mailing Address
First Line	:	505 E SHERIDAN AVE APT 2105
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73104-6715
Country	:	US
Telephone Number	:	601-951-6107
Fax Number	:

Provider Business Practice Location Address
First Line	:	1200 SW 104TH ST
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73139-3019
Country	:	US
Telephone Number	:	405-759-3773
Fax Number	:

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

Provider Enumeration Date	:	03/22/2023
Last Update Date	:	03/28/2023

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