Provider Demographics
NPI:1679793350
Name:JACKSON D. WAGNON, M.D.P.A.
Entity Type:Organization
Organization Name:JACKSON D. WAGNON, M.D.P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JACKSON
Authorized Official - Middle Name:
Authorized Official - Last Name:WAGNON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:936-634-8800
Mailing Address - Street 1:208 GASLIGHT BLVD
Mailing Address - Street 2:
Mailing Address - City:LUFKIN
Mailing Address - State:TX
Mailing Address - Zip Code:75904-3166
Mailing Address - Country:US
Mailing Address - Phone:936-634-8800
Mailing Address - Fax:936-634-8836
Practice Address - Street 1:208 GASLIGHT BLVD
Practice Address - Street 2:
Practice Address - City:LUFKIN
Practice Address - State:TX
Practice Address - Zip Code:75904-3166
Practice Address - Country:US
Practice Address - Phone:936-634-8800
Practice Address - Fax:936-634-8836
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-26
Last Update Date:2008-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG43680207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX144108101Medicaid
TXE43680Medicare UPIN
TX00385NMedicare PIN
TX144108101Medicaid