Healthcare Provider Details

I. General information

NPI: 1770391104
Provider Name (Legal Business Name): DEITRA RENEE POUGH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/18/2024
Last Update Date: 11/19/2025
Certification Date: 11/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

222 E MAIN ST
BARSTOW CA
92311-2361
US

IV. Provider business mailing address

12476 DEODAR ST
VICTORVILLE CA
92392-4838
US

V. Phone/Fax

Practice location:
  • Phone: 760-255-1496
  • Fax:
Mailing address:
  • Phone: 760-514-5244
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: