Basic Information
| Provider Information | |||||||||
| NPI: | 1700879624 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EVENSON | ||||||||
| FirstName: | JEFFREY | ||||||||
| MiddleName: | MARVIN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6355 S BUFFALO DR FL 3 | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891132133 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7022163346 | ||||||||
| FaxNumber: | 7026716883 | ||||||||
| Practice Location | |||||||||
| Address1: | 1000 S RAINBOW BLVD # B | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891456231 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7022554200 | ||||||||
| FaxNumber: | 7022550260 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/25/2005 | ||||||||
| LastUpdateDate: | 10/18/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/18/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 7648 | NV | Y | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | G65142 | CA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 20456 | AZ | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 28203 | CO | N | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 7648 | 01 | NV | STATE LICENSE | OTHER | P00892482 | 01 | NV | RAILROAD MEDICARE | OTHER | 1700879624 | 05 | NV | MEDICAID |