Provider Demographics
NPI:1720047079
Name:DEGATUR, WARREN J JR (MD)
Entity Type:Individual
Prefix:DR
First Name:WARREN
Middle Name:J
Last Name:DEGATUR
Suffix:JR
Gender:M
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:PO BOX 335
Mailing Address - Street 2:
Mailing Address - City:BREAUX BRIDGE
Mailing Address - State:LA
Mailing Address - Zip Code:70517-0335
Mailing Address - Country:US
Mailing Address - Phone:337-332-3500
Mailing Address - Fax:337-332-3200
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:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-23
Last Update Date:2007-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA017128207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1344940Medicaid
LA1344940Medicaid