1104832179 NPI number — CHRISTOPHER S DELOACHE D.O.

Table of content: CHRISTOPHER S DELOACHE D.O. (NPI 1104832179)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104832179 NPI number — CHRISTOPHER S DELOACHE D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DELOACHE
Provider First Name:
CHRISTOPHER
Provider Middle Name:
S
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
D.O.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1104832179
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/12/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1373 E. BOONE ST.
Provider Second Line Business Mailing Address:
SUITE 3401
Provider Business Mailing Address City Name:
TAHLEQUAH
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
74464-3234
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
918-456-6848
Provider Business Mailing Address Fax Number:
918-456-1150

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1373 E. BOONE ST.
Provider Second Line Business Practice Location Address:
SUITE 3401
Provider Business Practice Location Address City Name:
TAHLEQUAH
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
74464-3234
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
918-456-6848
Provider Business Practice Location Address Fax Number:
918-456-1150
Provider Enumeration Date:
07/31/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207X00000X , with the licence number:  3349 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 100256650B , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com