Provider Demographics
NPI:1437342615
Name:WAGGENSPACK, JEREMY LOUIS (MD)
Entity Type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:LOUIS
Last Name:WAGGENSPACK
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 1:6723 VICKSBURG ST
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70124-3321
Mailing Address - Country:US
Mailing Address - Phone:504-875-4029
Mailing Address - Fax:
Practice Address - Street 1:6723 VICKSBURG ST
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70124-3321
Practice Address - Country:US
Practice Address - Phone:504-875-4029
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-22
Last Update Date:2011-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD203258207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics