Provider Demographics
NPI:1144048687
Name:FUGATE, BEAREK DELAINE
Entity type:Individual
Prefix:MR
First Name:BEAREK
Middle Name:DELAINE
Last Name:FUGATE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:827 O ST NW APT 3
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:OK
Mailing Address - Zip Code:74354-2844
Mailing Address - Country:US
Mailing Address - Phone:918-325-3768
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:2024-10-02
Last Update Date:2024-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist