Provider Demographics
NPI:1124014659
Name:WAGUESPACK, KEITH A (MD)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:A
Last Name:WAGUESPACK
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 1:5001 S COOPER ST STE 201
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76017-5993
Mailing Address - Country:US
Mailing Address - Phone:866-367-8768
Mailing Address - Fax:817-541-9555
Practice Address - Street 1:2021 N MACARTHUR BLVD STE 450
Practice Address - Street 2:
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75061
Practice Address - Country:US
Practice Address - Phone:866-367-8768
Practice Address - Fax:817-541-9301
Is Sole Proprietor?:No
Enumeration Date:2005-09-20
Last Update Date:2019-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL7918208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX165039203Medicaid
TX165039204Medicaid
TX165039205Medicaid
TX165039201Medicaid
TX165039202Medicaid
TX8B7591Medicare PIN
TX8C2206Medicare PIN
TX165039205Medicaid
TX165039204Medicaid