Provider Demographics
NPI:1386684645
Name:WAGNON, JACKSON D (MD)
Entity Type:Individual
Prefix:DR
First Name:JACKSON
Middle Name:D
Last Name:WAGNON
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 1:208 GASLIGHT BLVD
Mailing Address - Street 2:
Mailing Address - City:LUFKIN
Mailing Address - State:TX
Mailing Address - Zip Code:75904-3166
Mailing Address - Country:US
Mailing Address - Phone:936-634-8800
Mailing Address - Fax:
Practice Address - Street 1:208 GASLIGHT BLVD
Practice Address - Street 2:
Practice Address - City:LUFKIN
Practice Address - State:TX
Practice Address - Zip Code:75904-3166
Practice Address - Country:US
Practice Address - Phone:936-634-8800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-07
Last Update Date:2011-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG8486207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX144108101Medicaid
TXE43680Medicare UPIN
TX00385NMedicare ID - Type UnspecifiedMEDICARE GRP