Provider Demographics
NPI:1457328213
Name:WEICHT, GRANT T (MD)
Entity Type:Individual
Prefix:DR
First Name:GRANT
Middle Name:T
Last Name:WEICHT
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 1:6055 N 2ND ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85012-1210
Mailing Address - Country:US
Mailing Address - Phone:602-870-5133
Mailing Address - Fax:
Practice Address - Street 1:1625 E NORTHERN AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85020-3960
Practice Address - Country:US
Practice Address - Phone:602-200-9021
Practice Address - Fax:602-200-9087
Is Sole Proprietor?:No
Enumeration Date:2006-03-01
Last Update Date:2011-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ28508207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZG84327Medicare UPIN
AZ63108Medicare ID - Type Unspecified