Provider Demographics
NPI:1073343828
Name:MIMBA, MARVIS
Entity type:Individual
Prefix:
First Name:MARVIS
Middle Name:
Last Name:MIMBA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2828 NW 57TH ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73112-6814
Mailing Address - Country:US
Mailing Address - Phone:405-418-4777
Mailing Address - Fax:
Practice Address - Street 1:4101 PERIMETER CENTER DR
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73112-2302
Practice Address - Country:US
Practice Address - Phone:563-766-7014
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-06
Last Update Date:2024-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK219763208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice