Provider Demographics
NPI:1902994528
Name:WACHTER, PAUL I (MD)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:I
Last Name:WACHTER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:177 BOVET ROAD, FL 6
Mailing Address - Street 2:BOVET PROF CENTER
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94402-3122
Mailing Address - Country:US
Mailing Address - Phone:701-255-9279
Mailing Address - Fax:888-384-0984
Practice Address - Street 1:327 N SAN MATEO DR
Practice Address - Street 2:STE 7
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94401-2585
Practice Address - Country:US
Practice Address - Phone:650-347-9146
Practice Address - Fax:650-343-3078
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2020-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG106542084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA260023398OtherRAILROAD MEDICARE
CA260023398OtherRAILROAD MEDICARE
A38032Medicare UPIN
00G106540Medicare PIN