Healthcare Provider Details

I. General information

NPI: 1366973851
Provider Name (Legal Business Name): CODY R WEAVER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2017
Last Update Date: 12/04/2025
Certification Date: 12/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

625 N 6TH ST
PHOENIX AZ
85004-2155
US

IV. Provider business mailing address

PO BOX 33269
PHOENIX AZ
85067-3269
US

V. Phone/Fax

Practice location:
  • Phone: 602-406-8222
  • Fax:
Mailing address:
  • Phone: 602-406-4786
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License Number77099
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: