Basic Information
| Provider Information | |||||||||
| NPI: | 1689663676 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EVANS | ||||||||
| FirstName: | GERALD | ||||||||
| MiddleName: | DAVID | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 937 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | NEW MILFORD | ||||||||
| State: | PA | ||||||||
| PostalCode: | 188347431 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5704653444 | ||||||||
| FaxNumber: | 5704655400 | ||||||||
| Practice Location | |||||||||
| Address1: | 937 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | NEW MILFORD | ||||||||
| State: | PA | ||||||||
| PostalCode: | 188347431 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5704653444 | ||||||||
| FaxNumber: | 5704655400 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/21/2005 | ||||||||
| LastUpdateDate: | 11/27/2012 | ||||||||
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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 | 111N00000X | DC04995L | PA | Y | Chiropractic Providers | Chiropractor |
ID Information
| ID | Type | State | Issuer | Description | 836180 | 01 | PA | AETNA | OTHER | 0012964820002 | 05 | PA | MEDICAID | 511796 | 01 | PA | BLUE SHIELD | OTHER |