Basic Information
| Provider Information | |||||||||
| NPI: | 1194813493 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WECHTER | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | ELLEN | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D., M.P.H. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 16568 | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322456568 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9044722300 | ||||||||
| FaxNumber: | 9044722330 | ||||||||
| Practice Location | |||||||||
| Address1: | 836 PRUDENTIAL DR | ||||||||
| Address2: | SUITE 1600 | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322078334 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043994862 | ||||||||
| FaxNumber: | 9044028948 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/11/2006 | ||||||||
| LastUpdateDate: | 02/07/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207VG0400X | ME101802 | FL | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 064350500 | 05 | FL | MEDICAID |