Provider Demographics
NPI:1679512974
Name:JIN, MARVIN Y (MD)
Entity type:Individual
Prefix:
First Name:MARVIN
Middle Name:Y
Last Name:JIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 140088
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74014-0088
Mailing Address - Country:US
Mailing Address - Phone:918-492-7722
Mailing Address - Fax:918-357-5859
Practice Address - Street 1:744 W 9TH ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74127-9020
Practice Address - Country:US
Practice Address - Phone:918-492-7722
Practice Address - Fax:918-357-5859
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-05
Last Update Date:2009-09-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OK109682084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100062150AMedicaid
C95091Medicare UPIN