Provider Demographics
NPI:1083454649
Name:DEITRICK, ZACHARY EUGENE
Entity type:Individual
Prefix:MR
First Name:ZACHARY
Middle Name:EUGENE
Last Name:DEITRICK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:ZAC
Other - Middle Name:
Other - Last Name:DEITRICK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:319 A ST SW
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:OK
Mailing Address - Zip Code:74354-7605
Mailing Address - Country:US
Mailing Address - Phone:918-544-6424
Mailing Address - Fax:
Practice Address - Street 1:319 A ST SW
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:OK
Practice Address - Zip Code:74354-7605
Practice Address - Country:US
Practice Address - Phone:918-544-6424
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-30
Last Update Date:2024-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist