Basic Information
| Provider Information | |||||||||
| NPI: | 1841202868 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DELOACH | ||||||||
| FirstName: | BRIAN | ||||||||
| MiddleName: | MIXON | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 984 PLANT DRIVE | ||||||||
| Address2: | |||||||||
| City: | STATESBORO | ||||||||
| State: | GA | ||||||||
| PostalCode: | 304600001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9124785641 | ||||||||
| FaxNumber: | 9124781893 | ||||||||
| Practice Location | |||||||||
| Address1: | 658 NORTHSIDE DR E STE A | ||||||||
| Address2: | |||||||||
| City: | STATESBORO | ||||||||
| State: | GA | ||||||||
| PostalCode: | 304584828 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9127649684 | ||||||||
| FaxNumber: | 9124898676 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/12/2006 | ||||||||
| LastUpdateDate: | 03/11/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/11/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 051216 | GA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 648007516A | 05 | GA | MEDICAID |