Provider Demographics
NPI:1619179421
Name:WAFER, MARTHA R (MD)
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:R
Last Name:WAFER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5400 E. TEXAS ST
Mailing Address - Street 2:
Mailing Address - City:BOSSIER CITY
Mailing Address - State:LA
Mailing Address - Zip Code:71111
Mailing Address - Country:US
Mailing Address - Phone:318-675-1313
Mailing Address - Fax:888-965-0619
Practice Address - Street 1:5400 E. TEXAS ST
Practice Address - Street 2:
Practice Address - City:BOSSIER CITY
Practice Address - State:LA
Practice Address - Zip Code:71111
Practice Address - Country:US
Practice Address - Phone:318-675-1313
Practice Address - Fax:888-965-0619
Is Sole Proprietor?:No
Enumeration Date:2007-06-04
Last Update Date:2022-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA026448207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA05981Medicaid