1992862148 NPI number — DR. JASON MARION EVANS O.D.

Table of content: DR. JASON MARION EVANS O.D. (NPI 1992862148)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992862148 NPI number — DR. JASON MARION EVANS O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
EVANS
Provider First Name:
JASON
Provider Middle Name:
MARION
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
O.D.
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:
1992862148
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/26/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1709 KY ROUTE 321 STE 3
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PRESTONSBURG
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
41653-9097
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
606-886-8546
Provider Business Mailing Address Fax Number:
606-886-8548

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6500 HIGHWAY 645
Provider Second Line Business Practice Location Address:
STE 110
Provider Business Practice Location Address City Name:
INEZ
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
41224
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-298-3412
Provider Business Practice Location Address Fax Number:
844-858-8954
Provider Enumeration Date:
01/03/2007

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: 152W00000X , with the licence number:  1637DT , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 77001410 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".




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