Provider Demographics
NPI:1841202868
Name:DELOACH, BRIAN MIXON (MD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:MIXON
Last Name:DELOACH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:984 PLANT DRIVE
Mailing Address - Street 2:
Mailing Address - City:STATESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30460-0001
Mailing Address - Country:US
Mailing Address - Phone:912-478-5641
Mailing Address - Fax:912-478-1893
Practice Address - Street 1:658 NORTHSIDE DR E STE A
Practice Address - Street 2:
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458-4828
Practice Address - Country:US
Practice Address - Phone:912-764-9684
Practice Address - Fax:912-489-8676
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2022-03-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA051216207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA648007516AMedicaid
GA08BBQDVMedicare ID - Type Unspecified