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General NPI Number Information
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NPI Number | 1558675157
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Entity Type | Individual
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Provider Name | MICHAEL WADE JORGENSEN OD
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Gender | Male
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Dates
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Enumeration Date | 08/06/2010
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Last Update Date | 11/16/2016
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Provider Practice Location Address
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Address Line | 187 BURT BLVD STE A
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City | BENTON
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State | LA
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Zip | 71006-4905
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Country | US
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Telephone | 318-935-5080
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Fax | 318-935-5085
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Provider Business Mailing Address
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Address Line | 187 BURT BLVD STE A
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City | BENTON
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State | LA
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Zip | 71006-4905
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Country | US
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Telephone | 318-935-5080
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Fax | 318-935-5085
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 1590-623T
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License Number State | LA
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