1699749127 NPI number — DR. EVAN M EVANS MD

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699749127 NPI number — DR. EVAN M EVANS MD

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:

EVANS

Provider First Name:

EVAN

Provider Middle Name:

M

Provider Name Prefix Text:

DR.

Provider Name Suffix Text:

Provider Credential Text:

MD

Provider Gender Code:

M

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:

1699749127

Entity Type Code:

Individual

Replacement NPI:

Last Update Date:

06/19/2023

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

PO BOX 841656

Provider Second Line Business Mailing Address:

Provider Business Mailing Address City Name:

DALLAS

Provider Business Mailing Address State Name:

TX

Provider Business Mailing Address Postal Code:

75284-1656

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

903-531-5000

Provider Business Mailing Address Fax Number:

Provider First Line Business Practice Location Address:

800 E DAWSON ST

Provider Second Line Business Practice Location Address:

Provider Business Practice Location Address City Name:

TYLER

Provider Business Practice Location Address State Name:

TX

Provider Business Practice Location Address Postal Code:

75701-2036

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

903-531-4500

Provider Business Practice Location Address Fax Number:

Provider Enumeration Date:

02/13/2006

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

Authorized Official Telephone Number:

• Taxonomy code: 2085R0202X , with the licence number:  H6201 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

• Identifier: 000000527435 . This is a "BS KY PROVIDER #" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
• Identifier: 103066009 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
• Identifier: 752616977007 . This is a "TRICARE TRINITY CLINIC" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
• Identifier: 8CU198 . This is a "BCBS MFH-JV-RBC LOCATION" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
• Identifier: 7100015000 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
• Identifier: 103066004 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
• Identifier: TIN PLUS 005 . This is a "TRICARE MFH-JV-RBC LOCATION" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
• Identifier: 103066008 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
• Identifier: 750818167013 . This is a "TRICARE MFH/ROSS BREAST CENTER" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
• Identifier: 8B0529 . This is a "BCBS MFH/ROSS BREAST CENTER" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
• Identifier: 8M8275 . This is a "BCBS TRINITY CLINIC" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
• Identifier: 752616977113 . This is a "TRICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".