Provider Demographics
NPI:1083685424
Name:HOMZA, WAYNE (MD)
Entity Type:Individual
Prefix:
First Name:WAYNE
Middle Name:
Last Name:HOMZA
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:PO BOX 9600
Mailing Address - Street 2:DEPT 09-033
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75505-9600
Mailing Address - Country:US
Mailing Address - Phone:877-243-8416
Mailing Address - Fax:
Practice Address - Street 1:2600 GREENWOOD RD
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71103-3908
Practice Address - Country:US
Practice Address - Phone:318-212-4550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-01
Last Update Date:2014-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA0171472085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1370363Medicaid
LA53595Medicare PIN
LAP00114671Medicare PIN