Basic Information
| Provider Information | |||||||||
| NPI: | 1801858865 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WEXLER | ||||||||
| FirstName: | MOSHE MARK | ||||||||
| MiddleName: | DOUGLAS | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PH.D. | ||||||||
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| OtherLastName: | WEXLER | ||||||||
| OtherFirstName: | MARK | ||||||||
| OtherMiddleName: | D | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PH.D. | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 586 OBSERVATORY DR | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809043959 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7196416275 | ||||||||
| FaxNumber: | 7196330150 | ||||||||
| Practice Location | |||||||||
| Address1: | 110 W. ENT AVE. BLDG 725 | ||||||||
| Address2: | 21 MDOS/SGOH | ||||||||
| City: | PAFB | ||||||||
| State: | CO | ||||||||
| PostalCode: | 80914 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7196416275 | ||||||||
| FaxNumber: | 7195567399 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/05/2006 | ||||||||
| LastUpdateDate: | 06/27/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103G00000X | 1863 | CO | Y | Behavioral Health & Social Service Providers | Clinical Neuropsychologist |
No ID Information.