Healthcare Provider Details

I. General information

NPI: 1831540608
Provider Name (Legal Business Name): ERIC WAETJEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/23/2016
Last Update Date: 08/02/2024
Certification Date: 08/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1747 IMPERIAL BLVD
LAKE CHARLES LA
70605-5362
US

IV. Provider business mailing address

1747 IMPERIAL BLVD
LAKE CHARLES LA
70605-5362
US

V. Phone/Fax

Practice location:
  • Phone: 337-721-7236
  • Fax: 337-721-7237
Mailing address:
  • Phone: 337-721-7236
  • Fax: 337-721-7237

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number2016020253
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number342862
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: