1801858865 NPI number — DR. MOSHE MARK DOUGLAS WEXLER PH.D.

Table of content: DR. MOSHE MARK DOUGLAS WEXLER PH.D. (NPI 1801858865)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801858865 NPI number — DR. MOSHE MARK DOUGLAS WEXLER PH.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WEXLER
Provider First Name:
MOSHE MARK
Provider Middle Name:
DOUGLAS
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PH.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WEXLER
Provider Other First Name:
MARK
Provider Other Middle Name:
D
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
PH.D.
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1801858865
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/27/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
586 OBSERVATORY DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COLORADO SPRINGS
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80904-3959
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
719-641-6275
Provider Business Mailing Address Fax Number:
719-633-0150

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
110 W. ENT AVE. BLDG 725
Provider Second Line Business Practice Location Address:
21 MDOS/SGOH
Provider Business Practice Location Address City Name:
PAFB
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80914
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
719-641-6275
Provider Business Practice Location Address Fax Number:
719-556-7399
Provider Enumeration Date:
04/05/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103G00000X , with the licence number:  1863 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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