Provider Demographics
NPI:1174016083
Name:DELOACH, EUGENE JR (DPT)
Entity Type:Individual
Prefix:
First Name:EUGENE
Middle Name:
Last Name:DELOACH
Suffix:JR
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19108 BAJO DR
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73012-2654
Mailing Address - Country:US
Mailing Address - Phone:580-583-5039
Mailing Address - Fax:
Practice Address - Street 1:6729 NW 39TH EXPY
Practice Address - Street 2:
Practice Address - City:BETHANY
Practice Address - State:OK
Practice Address - Zip Code:73008-2605
Practice Address - Country:US
Practice Address - Phone:405-717-6290
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-14
Last Update Date:2018-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK54562251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic