Provider Demographics
NPI:1104832179
Name:DELOACHE, CHRISTOPHER S (DO)
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:S
Last Name:DELOACHE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1373 E. BOONE ST.
Mailing Address - Street 2:SUITE 3401
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74464-3234
Mailing Address - Country:US
Mailing Address - Phone:918-456-6848
Mailing Address - Fax:918-456-1150
Practice Address - Street 1:1373 E. BOONE ST.
Practice Address - Street 2:SUITE 3401
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464-3234
Practice Address - Country:US
Practice Address - Phone:918-456-6848
Practice Address - Fax:918-456-1150
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2012-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3349207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100256650BMedicaid
OKG83629Medicare UPIN
OK100256650BMedicaid