Basic Information
| Provider Information | |||||||||
| NPI: | 1346260247 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLACK | ||||||||
| FirstName: | EVAN | ||||||||
| MiddleName: | GEORGE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5323 WOODROW ST | ||||||||
| Address2: | #201 | ||||||||
| City: | MURRAY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841075841 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8012614711 | ||||||||
| FaxNumber: | 8012614769 | ||||||||
| Practice Location | |||||||||
| Address1: | 5323 WOODROW ST | ||||||||
| Address2: | #201 | ||||||||
| City: | MURRAY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841075841 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8012614711 | ||||||||
| FaxNumber: | 8012614769 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/20/2006 | ||||||||
| LastUpdateDate: | 11/09/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 11/09/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | MD476184 | PA | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084N0400X | 187597-1205 | UT | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084N0400X | 99622 | MT | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084N0400X | 21619 | NH | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084N0400X | 89191 | GA | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084N0400X | MD205738 | OR | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
No ID Information.