MEDICARE: DR. JEREMY LOUIS WAGGENSPACK M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	MD203258	LA
2	208000000X	Pediatrics Physician	MD203258	LA

General Provider Information

NPI Number	:	1437342615
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JEREMY LOUIS WAGGENSPACK M.D.

Provider Business Mailing Address
First Line	:	6723 VICKSBURG ST
Second Line	:
City	:	NEW ORLEANS
State	:	LA
Zip	:	70124-3321
Country	:	US
Telephone Number	:	504-875-4029
Fax Number	:

Provider Business Practice Location Address
First Line	:	6723 VICKSBURG ST
Second Line	:
City	:	NEW ORLEANS
State	:	LA
Zip	:	70124-3321
Country	:	US
Telephone Number	:	504-875-4029
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/22/2007
Last Update Date	:	03/11/2011

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