1770557373 NPI number — DR. LARRY W EVANS DO

Table of content: DR. LARRY W EVANS DO (NPI 1770557373)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770557373 NPI number — DR. LARRY W EVANS DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
EVANS
Provider First Name:
LARRY
Provider Middle Name:
W
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DO
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:
1770557373
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/30/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6202 IOLA AVE STE 101
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LUBBOCK
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
79424-2729
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
806-799-2093
Provider Business Mailing Address Fax Number:
806-783-0277

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6202 IOLA AVE STE 101
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LUBBOCK
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
79424-2729
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
806-799-2093
Provider Business Practice Location Address Fax Number:
806-783-0277
Provider Enumeration Date:
02/13/2006

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: 207LP2900X , with the licence number:  H6203 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207L00000X , with the licence number: H6203 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 134049911 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 752616977065 . This is a "TRICARE CHAMPUS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: P00253558 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 152248403 . This is a "EPSDT" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 5683525 . This is a "AETNA" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: EV08J0375 . This is a "BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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