Provider Demographics
NPI:1700840964
Name:DELOACH, JOE WESLEY (OD)
Entity Type:Individual
Prefix:DR
First Name:JOE
Middle Name:WESLEY
Last Name:DELOACH
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2525 LUCAS DR
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75219-1804
Mailing Address - Country:US
Mailing Address - Phone:214-528-7354
Mailing Address - Fax:214-528-7387
Practice Address - Street 1:505 J DAVIS ARMISTEAD BLDG
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77204-2020
Practice Address - Country:US
Practice Address - Phone:713-743-1921
Practice Address - Fax:713-743-0963
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-14
Last Update Date:2014-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2828TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX112409105Medicaid
TX127237908Medicaid
TX127237908Medicaid
TX00395ZMedicare PIN
TX00E63GMedicare UPIN
TX8F1003Medicare UPIN