Provider Demographics
NPI:1689077612
Name:DESHAZO, PHYLLIS R (REEGT, CNIM)
Entity Type:Individual
Prefix:MRS
First Name:PHYLLIS
Middle Name:R
Last Name:DESHAZO
Suffix:
Gender:F
Credentials:REEGT, CNIM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:409 E CALIFORNIA AVE
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73104-4224
Mailing Address - Country:US
Mailing Address - Phone:405-841-7826
Mailing Address - Fax:405-841-7827
Practice Address - Street 1:409 E CALIFORNIA AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73104-4224
Practice Address - Country:US
Practice Address - Phone:405-841-7826
Practice Address - Fax:405-841-7827
Is Sole Proprietor?:No
Enumeration Date:2014-10-05
Last Update Date:2014-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK466246ZE0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZE0600XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherElectroneurodiagnostic