1063406056 NPI number — DR. CLIFFORD L EVANS MD

Table of content: DR. CLIFFORD L EVANS MD (NPI 1063406056)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063406056 NPI number — DR. CLIFFORD L EVANS MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
EVANS
Provider First Name:
CLIFFORD
Provider Middle Name:
L
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
EVANS
Provider Other First Name:
CLIFFORD
Provider Other Middle Name:
L
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1063406056
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/17/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 905
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MORRILTON
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72110-0905
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
501-354-9746
Provider Business Mailing Address Fax Number:
501-354-0553

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
912 E DRILLING ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MORRILTON
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72110-2218
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
501-354-9746
Provider Business Practice Location Address Fax Number:
501-354-0553
Provider Enumeration Date:
09/06/2005

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: 207Q00000X , with the licence number:  C3306 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 020548706 . This is a "THE PRUDENTAL-AARP CLAIMS" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: 080191177 . This is a "PALMETTO GBA" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: 121959001 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4099493 . This is a "AETNA" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: 51594 . This is a "BC/BS" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: 020548706 . This is a "FIRST HEALTH" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: A37553 . This is a "CIGNA HEALTHCARE" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: 0100555 . This is a "UNITED HEALTH CARE" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: 020548706 . This is a "TRICARE" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: 020548706 . This is a "AMCO" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: 02120016500 . This is a "QUALCHOICE" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".




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