Provider Demographics
NPI:1801858865
Name:WEXLER, MOSHE MARK DOUGLAS (PHD)
Entity Type:Individual
Prefix:DR
First Name:MOSHE MARK
Middle Name:DOUGLAS
Last Name:WEXLER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:DR
Other - First Name:MARK
Other - Middle Name:D
Other - Last Name:WEXLER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:586 OBSERVATORY DR
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80904-3959
Mailing Address - Country:US
Mailing Address - Phone:719-641-6275
Mailing Address - Fax:719-633-0150
Practice Address - Street 1:110 W. ENT AVE. BLDG 725
Practice Address - Street 2:21 MDOS/SGOH
Practice Address - City:PAFB
Practice Address - State:CO
Practice Address - Zip Code:80914
Practice Address - Country:US
Practice Address - Phone:719-641-6275
Practice Address - Fax:719-556-7399
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-05
Last Update Date:2012-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1863103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist