Provider Demographics
NPI:1477968188
Name:WADHWA, ANANT
Entity Type:Individual
Prefix:
First Name:ANANT
Middle Name:
Last Name:WADHWA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:190 E BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6241
Mailing Address - Country:US
Mailing Address - Phone:208-381-8752
Mailing Address - Fax:
Practice Address - Street 1:125 E IDAHO ST STE 300
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83712-6256
Practice Address - Country:US
Practice Address - Phone:208-381-7335
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-23
Last Update Date:2023-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20140142552084N0400X
IDM-149352084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2014014255OtherMISSOURI TEMPORARY LICENSE NUMBER