Basic Information
| Provider Information | |||||||||
| NPI: | 1902994528 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WACHTER | ||||||||
| FirstName: | PAUL | ||||||||
| MiddleName: | I | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 177 BOVET ROAD, FL 6 | ||||||||
| Address2: | BOVET PROF CENTER | ||||||||
| City: | SAN MATEO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 944023122 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7012559279 | ||||||||
| FaxNumber: | 8883840984 | ||||||||
| Practice Location | |||||||||
| Address1: | 327 N SAN MATEO DR | ||||||||
| Address2: | STE 7 | ||||||||
| City: | SAN MATEO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 944012585 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6503479146 | ||||||||
| FaxNumber: | 6503433078 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/10/2006 | ||||||||
| LastUpdateDate: | 02/11/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 02/11/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | G10654 | CA | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 260023398 | 01 | CA | RAILROAD MEDICARE | OTHER |