Provider Demographics
NPI:1699021410
Name:GARY M. AGENA MD LLC
Entity Type:Organization
Organization Name:GARY M. AGENA MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:AGENA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:985-845-7121
Mailing Address - Street 1:393 HIGHWAY 21
Mailing Address - Street 2:SUITE 525
Mailing Address - City:MADISONVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70447-3407
Mailing Address - Country:US
Mailing Address - Phone:985-845-7121
Mailing Address - Fax:985-206-9476
Practice Address - Street 1:393 HIGHWAY 21
Practice Address - Street 2:SUITE 525
Practice Address - City:MADISONVILLE
Practice Address - State:LA
Practice Address - Zip Code:70447-3407
Practice Address - Country:US
Practice Address - Phone:985-845-7121
Practice Address - Fax:985-206-9476
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-30
Last Update Date:2012-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD200946261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1504050Medicaid
LA4K301Medicare UPIN