Provider Demographics
NPI:1013983295
Name:WAGUESPACK, ROLAND S JR (MD)
Entity Type:Individual
Prefix:MR
First Name:ROLAND
Middle Name:S
Last Name:WAGUESPACK
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 1:1108 ST JAMES ST
Mailing Address - Street 2:
Mailing Address - City:VACHERIE
Mailing Address - State:LA
Mailing Address - Zip Code:70090
Mailing Address - Country:US
Mailing Address - Phone:225-265-4087
Mailing Address - Fax:225-265-4678
Practice Address - Street 1:1108 ST JAMES ST
Practice Address - Street 2:
Practice Address - City:VACHERIE
Practice Address - State:LA
Practice Address - Zip Code:70090
Practice Address - Country:US
Practice Address - Phone:225-265-4087
Practice Address - Fax:225-265-4678
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA009974207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1090123Medicaid
B61001Medicare UPIN
LA1090123Medicaid