1003072604 NPI number — DR. J.RICHARD LEE EVANSON D.O.

Table of content: DR. J.RICHARD LEE EVANSON D.O. (NPI 1003072604)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003072604 NPI number — DR. J.RICHARD LEE EVANSON D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
EVANSON
Provider First Name:
J.RICHARD
Provider Middle Name:
LEE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.O.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1003072604
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/21/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
300 W HOSPITAL ROAD, ROOM 11C17
Provider Second Line Business Mailing Address:
EISENHOWER ARMY MEDICAL CENTER
Provider Business Mailing Address City Name:
FORT GORDON
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30905-5650
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
706-787-4657
Provider Business Mailing Address Fax Number:
706-787-1745

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
300 W HOSPITAL ROAD, ROOM 11C17 ATTN: OFFICE OF GME
Provider Second Line Business Practice Location Address:
EISENHOWER ARMY MEDICAL CENTER
Provider Business Practice Location Address City Name:
FORT GORDON
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30905-5650
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-787-4657
Provider Business Practice Location Address Fax Number:
706-787-1745
Provider Enumeration Date:
08/03/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207X00000X , with the licence number:  63653 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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