Provider Demographics
NPI:1902350085
Name:WERVEN, CODY (IDC)
Entity Type:Individual
Prefix:MR
First Name:CODY
Middle Name:
Last Name:WERVEN
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 LESTERTOWN RD
Mailing Address - Street 2:
Mailing Address - City:GROTON
Mailing Address - State:CT
Mailing Address - Zip Code:06340-2817
Mailing Address - Country:US
Mailing Address - Phone:847-271-7404
Mailing Address - Fax:
Practice Address - Street 1:150 LESTERTOWN RD
Practice Address - Street 2:
Practice Address - City:GROTON
Practice Address - State:CT
Practice Address - Zip Code:06340-2817
Practice Address - Country:US
Practice Address - Phone:847-271-7404
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-06
Last Update Date:2016-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians