Provider Demographics
NPI:1417168642
Name:WAGER, JOHN (PHD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:WAGER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2485 HOSPITAL DR
Mailing Address - Street 2:SUITE #351
Mailing Address - City:MOUNTAIN VIEW
Mailing Address - State:CA
Mailing Address - Zip Code:94040-4101
Mailing Address - Country:US
Mailing Address - Phone:650-687-7322
Mailing Address - Fax:650-988-7674
Practice Address - Street 1:2485 HOSPITAL DR
Practice Address - Street 2:SUITE #351
Practice Address - City:MOUNTAIN VIEW
Practice Address - State:CA
Practice Address - Zip Code:94040-4101
Practice Address - Country:US
Practice Address - Phone:650-687-7322
Practice Address - Fax:650-988-7674
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-28
Last Update Date:2015-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA23806103G00000X, 103T00000X, 103TR0400X, 103TC0700X
NY019003103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitation
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA46-3467093OtherTAX IDENTIFICATION
NYJ400041854Medicare PIN