Provider Demographics
NPI:1316074115
Name:WAGNER, L. DAVID (MED)
Entity type:Individual
Prefix:
First Name:L.
Middle Name:DAVID
Last Name:WAGNER
Suffix:
Gender:M
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3001 5TH ST
Mailing Address - Street 2:# 300
Mailing Address - City:METAIRIE
Mailing Address - State:LA
Mailing Address - Zip Code:70002-1865
Mailing Address - Country:US
Mailing Address - Phone:504-836-0000
Mailing Address - Fax:504-832-4040
Practice Address - Street 1:3001 5TH ST
Practice Address - Street 2:# 300
Practice Address - City:METAIRIE
Practice Address - State:LA
Practice Address - Zip Code:70002-1865
Practice Address - Country:US
Practice Address - Phone:504-836-0000
Practice Address - Fax:504-832-4040
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA2014101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional