Provider Demographics
NPI:1962498568
Name:WECHSLER, ROBERT T (MD, PHD, FAAN)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:T
Last Name:WECHSLER
Suffix:
Gender:M
Credentials:MD, PHD, FAAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1499 WEST HAYS STREET
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702
Mailing Address - Country:US
Mailing Address - Phone:208-381-7353
Mailing Address - Fax:208-381-7354
Practice Address - Street 1:1499 W. HAYS ST.
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702
Practice Address - Country:US
Practice Address - Phone:208-275-8585
Practice Address - Fax:208-275-8586
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-20
Last Update Date:2015-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM92212084N0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0600XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyClinical Neurophysiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807254701Medicaid
ID000010151186OtherREGENCE BLUE SHIELD
ID75135OtherBLUE CROSS OF IDAHO
ID807254700Medicaid
ID000010151186OtherREGENCE BLUE SHIELD
1131222Medicare ID - Type Unspecified