Provider Demographics
NPI:1679681894
Name:DELOACH, MARK A (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:DELOACH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 723
Mailing Address - Street 2:
Mailing Address - City:BAY SPRINGS
Mailing Address - State:MS
Mailing Address - Zip Code:39422-0723
Mailing Address - Country:US
Mailing Address - Phone:601-340-3544
Mailing Address - Fax:601-651-2926
Practice Address - Street 1:16 S SIXTH ST
Practice Address - Street 2:
Practice Address - City:BAY SPRINGS
Practice Address - State:MS
Practice Address - Zip Code:39422-9055
Practice Address - Country:US
Practice Address - Phone:601-764-4501
Practice Address - Fax:601-764-2310
Is Sole Proprietor?:No
Enumeration Date:2006-08-28
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MS14545207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
822838OtherWELLCARE