Provider Demographics
NPI:1902882186
Name:OAKLEY, DERREK SHANE (DC)
Entity Type:Individual
Prefix:
First Name:DERREK
Middle Name:SHANE
Last Name:OAKLEY
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1708
Mailing Address - Street 2:
Mailing Address - City:PRAIRIEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70769-1708
Mailing Address - Country:US
Mailing Address - Phone:225-677-7777
Mailing Address - Fax:225-677-7778
Practice Address - Street 1:17487 OLD JEFFERSON HWY
Practice Address - Street 2:
Practice Address - City:PRAIRIEVILLE
Practice Address - State:LA
Practice Address - Zip Code:70769-4018
Practice Address - Country:US
Practice Address - Phone:225-677-7777
Practice Address - Fax:225-677-7778
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1118111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAF0756OtherBLUE CROSS BLUE SHIELD
LA5X333Medicare ID - Type Unspecified
LAU67207Medicare UPIN