Provider Demographics
NPI:1144677899
Name:DR. MICHAEL WADE JORGENSEN OD LLC
Entity type:Organization
Organization Name:DR. MICHAEL WADE JORGENSEN OD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:WADE
Authorized Official - Last Name:JORGENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:318-935-5080
Mailing Address - Street 1:187 BURT BLVD
Mailing Address - Street 2:STE A
Mailing Address - City:BENTON
Mailing Address - State:LA
Mailing Address - Zip Code:71006-4905
Mailing Address - Country:US
Mailing Address - Phone:318-935-5080
Mailing Address - Fax:318-935-5085
Practice Address - Street 1:187 BURT BLVD
Practice Address - Street 2:STE A
Practice Address - City:BENTON
Practice Address - State:LA
Practice Address - Zip Code:71006-4905
Practice Address - Country:US
Practice Address - Phone:318-935-5080
Practice Address - Fax:318-935-5085
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-23
Last Update Date:2016-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1590623T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2394495Medicaid