Basic Information
Provider Information | |||||||||
NPI: | 1184835613 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | FREEDMAN | ||||||||
FirstName: | EVAN | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | DO | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 18444 N 25TH AVE | ||||||||
Address2: | STE 310 | ||||||||
City: | PHOENIX | ||||||||
State: | AZ | ||||||||
PostalCode: | 850231266 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8669742673 | ||||||||
FaxNumber: | 8669392673 | ||||||||
Practice Location | |||||||||
Address1: | 10503 W THUNDERBIRD BLVD | ||||||||
Address2: | STE 262 | ||||||||
City: | SUN CITY | ||||||||
State: | AZ | ||||||||
PostalCode: | 853513022 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8669742673 | ||||||||
FaxNumber: | 8669392673 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/25/2007 | ||||||||
LastUpdateDate: | 07/19/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 005906 | AZ | N |   | Other Service Providers | Specialist |   | 2084N0400X | 005906 | AZ | N |   | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084P0800X | 005906 | AZ | N |   | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084P2900X | 005906 | AZ | Y |   | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Pain Medicine |
ID Information
ID | Type | State | Issuer | Description | 005906 | 01 | AZ | AZ MEDICAL LICENSE | OTHER | 710004 | 05 | AZ |   | MEDICAID |