Provider Demographics
NPI:1396951307
Name:RANDALL K WAGMAN MD APMC
Entity type:Organization
Organization Name:RANDALL K WAGMAN MD APMC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:
Authorized Official - Last Name:WAGMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:337-439-1484
Mailing Address - Street 1:2345 SAMPSON ST
Mailing Address - Street 2:
Mailing Address - City:WESTLAKE
Mailing Address - State:LA
Mailing Address - Zip Code:70669-2711
Mailing Address - Country:US
Mailing Address - Phone:337-439-1484
Mailing Address - Fax:337-430-0927
Practice Address - Street 1:2345 SAMPSON ST
Practice Address - Street 2:
Practice Address - City:WESTLAKE
Practice Address - State:LA
Practice Address - Zip Code:70669-2711
Practice Address - Country:US
Practice Address - Phone:337-439-1484
Practice Address - Fax:337-430-0927
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA11202R207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1945323Medicaid
LA5C375Medicare ID - Type Unspecified