Provider Demographics
NPI:1154358836
Name:WEIDEN, EVAN T (MD)
Entity type:Individual
Prefix:
First Name:EVAN
Middle Name:T
Last Name:WEIDEN
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 1:6644 E BAYWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85296
Mailing Address - Country:US
Mailing Address - Phone:480-266-1911
Mailing Address - Fax:
Practice Address - Street 1:6644 E BAYWOOD AVE
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206-1747
Practice Address - Country:US
Practice Address - Phone:480-266-1911
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2015-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ426452084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI60170OtherDEAN HEALTH INSURANCE
WI34389800Medicaid
WI34389800Medicaid
WI083474150Medicare PIN
WIP00050918Medicare PIN
AZZ141958Medicare PIN