Basic Information
| Provider Information | |||||||||
| NPI: | 1699749127 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EVANS | ||||||||
| FirstName: | EVAN | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 841656 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752841656 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9035315000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 800 E DAWSON ST | ||||||||
| Address2: | |||||||||
| City: | TYLER | ||||||||
| State: | TX | ||||||||
| PostalCode: | 757012036 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9035314500 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/13/2006 | ||||||||
| LastUpdateDate: | 10/13/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | H6201 | TX | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 752616977007 | 01 | TX | TRICARE TRINITY CLINIC | OTHER | 8CU198 | 01 | TX | BCBS MFH-JV-RBC LOCATION | OTHER | 7100015000 | 05 | KY | MEDICAID | 000000527435 | 01 | KY | BS KY PROVIDER # | OTHER | 103066008 | 05 | TX | MEDICAID | 8B0529 | 01 | TX | BCBS MFH/ROSS BREAST CENTER | OTHER | 752616977113 | 01 | TX | TRICARE | OTHER | 8M8275 | 01 | TX | BCBS TRINITY CLINIC | OTHER | TIN PLUS 005 | 01 | TX | TRICARE MFH-JV-RBC LOCATION | OTHER | 103066004 | 05 | TX | MEDICAID | 750818167013 | 01 | TX | TRICARE MFH/ROSS BREAST CENTER | OTHER | 103066009 | 05 | TX | MEDICAID |