1326335514 NPI number — DR. EVORA JUANITA BRENT MD

Table of content: DR. EVORA JUANITA BRENT MD (NPI 1326335514)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1326335514 NPI number — DR. EVORA JUANITA BRENT MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRENT
Provider First Name:
EVORA
Provider Middle Name:
JUANITA
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
NEWBY
Provider Other First Name:
EVORA
Provider Other Middle Name:
JUANITA
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1326335514
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/24/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2650 RIDGE AVE ROOM 1223
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EVANSTON
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60201-1718
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
847-570-2040
Provider Business Mailing Address Fax Number:
847-733-5315

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1000 CENTRAL ST.
Provider Second Line Business Practice Location Address:
SUITE 800
Provider Business Practice Location Address City Name:
EVANSTON
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60201-1780
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
847-570-2577
Provider Business Practice Location Address Fax Number:
847-733-5424
Provider Enumeration Date:
07/07/2011

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: 2080P0006X , with the licence number:  036138274 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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