Provider Demographics
NPI:1609202332
Name:JOHN H WAGNER,III,MD,LLC
Entity Type:Organization
Organization Name:JOHN H WAGNER,III,MD,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:H
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:318-221-8525
Mailing Address - Street 1:1002 HIGHLAND AVE
Mailing Address - Street 2:STE 300
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71101-4143
Mailing Address - Country:US
Mailing Address - Phone:318-221-8525
Mailing Address - Fax:318-221-8526
Practice Address - Street 1:1002 HIGHLAND AVE
Practice Address - Street 2:STE 300
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101-4143
Practice Address - Country:US
Practice Address - Phone:318-221-8525
Practice Address - Fax:318-221-8526
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-26
Last Update Date:2013-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty