Provider Demographics
NPI:1023068350
Name:PITRE, WAYNE MICHAEL (MD)
Entity type:Individual
Prefix:DR
First Name:WAYNE
Middle Name:MICHAEL
Last Name:PITRE
Suffix:
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 1:1202 MISSION PARK DR
Mailing Address - Street 2:
Mailing Address - City:VICKSBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39180-3758
Mailing Address - Country:US
Mailing Address - Phone:601-636-6675
Mailing Address - Fax:
Practice Address - Street 1:1202 MISSION PARK DR
Practice Address - Street 2:
Practice Address - City:VICKSBURG
Practice Address - State:MS
Practice Address - Zip Code:39180-3758
Practice Address - Country:US
Practice Address - Phone:601-636-6675
Practice Address - Fax:601-636-6677
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-10
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS09371174400000X
LAMD.013940174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS39325OtherLABC
MS09371OtherSTATE ID NUMBER
MS09371OtherSTATE ID NUMBER
MS39325OtherLABC
MS07000001092249Medicare ID - Type Unspecified