Provider Demographics
NPI:1568654689
Name:WARREN J. DEGATUR, JR. MD INC
Entity Type:Organization
Organization Name:WARREN J. DEGATUR, JR. MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL RECORDS
Authorized Official - Prefix:
Authorized Official - First Name:RAMONA
Authorized Official - Middle Name:
Authorized Official - Last Name:FOSTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:337-332-3500
Mailing Address - Street 1:206 CHAMPAGNE BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:BREAUX BRIDGE
Mailing Address - State:LA
Mailing Address - Zip Code:70517-3700
Mailing Address - Country:US
Mailing Address - Phone:337-332-3500
Mailing Address - Fax:
Practice Address - Street 1:206 CHAMPAGNE BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:BREAUX BRIDGE
Practice Address - State:LA
Practice Address - Zip Code:70517-3700
Practice Address - Country:US
Practice Address - Phone:337-332-3500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-13
Last Update Date:2010-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA017128207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1720047079OtherNPI-INDVIDUAL
LA1949329Medicaid
LA1949329Medicaid
B62901Medicare UPIN