Basic Information
| Provider Information | |||||||||
| NPI: | 1548216492 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | EVANS | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | P. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 90 JACKSON PIKE | ||||||||
| Address2: | |||||||||
| City: | GALLIPOLIS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456311560 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7404411934 | ||||||||
| FaxNumber: | 7404465982 | ||||||||
| Practice Location | |||||||||
| Address1: | 280 PATTONSVILLE RD | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456409452 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403958805 | ||||||||
| FaxNumber: | 7403958855 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/25/2006 | ||||||||
| LastUpdateDate: | 11/16/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 35-04-4543 | OH | Y | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 15253 | WV | N | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0083149000 | 05 | WV | MEDICAID | 0417838 | 01 | OH | MOLINA MEDICAID | OTHER | 0417838 | 05 | OH | MEDICAID | 310917085075 | 01 | OH | CARESOURCE MEDICAID | OTHER | 000000181849 | 01 | OH | UNISON MEDICAID | OTHER | 001714032 | 01 | MOUNTAIN STATE BCBS | OTHER | 000000007676 | 01 | ANTHEM BCBS | OTHER | C30674 | 01 | RR MEDICARE | OTHER |