Provider Demographics
NPI:1558675157
Name:JORGENSEN, MICHAEL WADE (OD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:WADE
Last Name:JORGENSEN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:187 BURT BLVD
Mailing Address - Street 2:STE A
Mailing Address - City:BENTON
Mailing Address - State:LA
Mailing Address - Zip Code:71006-4905
Mailing Address - Country:US
Mailing Address - Phone:318-935-5080
Mailing Address - Fax:318-935-5085
Practice Address - Street 1:187 BURT BLVD
Practice Address - Street 2:STE A
Practice Address - City:BENTON
Practice Address - State:LA
Practice Address - Zip Code:71006-4905
Practice Address - Country:US
Practice Address - Phone:318-935-5080
Practice Address - Fax:318-935-5085
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-06
Last Update Date:2016-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1590-623T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist