Provider Demographics
NPI:1609654292
Name:DELOACH, DEBORAH K (LDO)
Entity Type:Individual
Prefix:MS
First Name:DEBORAH
Middle Name:K
Last Name:DELOACH
Suffix:
Gender:F
Credentials:LDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3109 E 1ST ST
Mailing Address - Street 2:
Mailing Address - City:VIDALIA
Mailing Address - State:GA
Mailing Address - Zip Code:30474-8830
Mailing Address - Country:US
Mailing Address - Phone:912-537-2436
Mailing Address - Fax:912-537-2659
Practice Address - Street 1:3109 E 1ST ST
Practice Address - Street 2:
Practice Address - City:VIDALIA
Practice Address - State:GA
Practice Address - Zip Code:30474-8830
Practice Address - Country:US
Practice Address - Phone:912-537-2436
Practice Address - Fax:912-537-2659
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-15
Last Update Date:2023-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALDO002114156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician