Provider Demographics
NPI:1033320577
Name:WAGNER, JOHN (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:WAGNER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7330 FERN AVE STE 704
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71105-4985
Mailing Address - Country:US
Mailing Address - Phone:318-798-8261
Mailing Address - Fax:316-798-8263
Practice Address - Street 1:7330 FERN AVE STE 704
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105-4985
Practice Address - Country:US
Practice Address - Phone:318-798-8261
Practice Address - Fax:316-798-8263
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-25
Last Update Date:2019-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.2012302084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1214841Medicaid
LA4P278F600OtherMEDICARE - PTAN