Basic Information
Provider Information | |||||||||
NPI: | 1659486348 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WECHTER | ||||||||
FirstName: | DAVID | ||||||||
MiddleName: | T | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 29373 NETWORK PL | ||||||||
Address2: |   | ||||||||
City: | CHICAGO | ||||||||
State: | IL | ||||||||
PostalCode: | 606731293 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8473905900 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2535 SOUTH MARTIN LUTHER KING DRIVE | ||||||||
Address2: |   | ||||||||
City: | CHICAGO | ||||||||
State: | IL | ||||||||
PostalCode: | 60616 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3128427117 | ||||||||
FaxNumber: | 3123262102 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/20/2006 | ||||||||
LastUpdateDate: | 09/29/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 12/09/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 036061251 | IL | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 01379 | 01 | IL | BLUE CHOICE | OTHER | 362664182 | 01 |   | HUMANA | OTHER | 362664182 | 01 |   | UNITED HEALTHCARE | OTHER | 036061251 | 05 | IL |   | MEDICAID | 0004075081 | 01 |   | AETNA | OTHER | 0001616367 | 01 | IL | BLUE CROSS BLUE SHIELD | OTHER | 110041791 | 01 |   | RR MEDICARE | OTHER | 362664182 | 01 |   | CIGNA | OTHER |