Provider Demographics
NPI:1356755110
Name:NEBEKER, CODY (MD)
Entity type:Individual
Prefix:
First Name:CODY
Middle Name:
Last Name:NEBEKER
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 1:2950 N CHURCH ST STE 301
Mailing Address - Street 2:
Mailing Address - City:LAYTON
Mailing Address - State:UT
Mailing Address - Zip Code:84040-6590
Mailing Address - Country:US
Mailing Address - Phone:801-771-7771
Mailing Address - Fax:
Practice Address - Street 1:970 MEDICAL DR STE 202
Practice Address - Street 2:
Practice Address - City:BRIGHAM CITY
Practice Address - State:UT
Practice Address - Zip Code:84302-3286
Practice Address - Country:US
Practice Address - Phone:435-695-2273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-19
Last Update Date:2022-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301105892208600000X
UT6034453-1205208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5315066446OtherCONTROLLED SUBSTANCE
MI4301105892OtherMEIDCAL LICENSE